1-866-822-1798 inforequest@bcservice.com

bc services red icon SUBMIT A CLAIM

If you would like more information on our services, please call us at 1-800-732-0262. You may also submit a claim using the form below. We’re happy to answer any questions or respond to your comments.

YOU MAY ONLY LIST UP TO 5 ACCOUNTS USING THIS FORM! For listings of more than 5 accounts, please contact our customer service department for help with an easier process of listing submission.

Yes This is the first time I have submitted a claim listing to BC Services.
Your Account Number:
Debtor's Name:
Debtor's Spouse Name:
Debtor's Social Security Number:
Debtor's DOB:
Debtor's Mailing Address:   last known
City, State, Zip:
Debtor's Home Phone:
Debtor's Cell Phone:
Total Principal Balance:
Debtor's Employer:
Date of Last Payment:
Date of Service:
Date of Delinquency:
Other
helpful information

about debtor:
 
 
(For Example: references, nearest living relative, parents' names
PLEASE KEEP INFORMATION FIELDS 25 CHARACTERS OR LESS)

Client Number*:
* For new clients, leave this field blank and fill in information below.
  For existing clients, just fill in client number and email address field below.
Name:
Street Address:
City, State, Zip:
Phone:
Email Address:
By:
(Name of authorized representative)

For value received, I hereby assign and transfer to BC Services, Inc., a Colorado corporation, assignee our account and claim against the debtor shown above in the amount shown above, plus interest, with full authority to take whatever steps necessary to collect and satisfy the same. The undersigned warrants that the account hereby assigned is a valid debt now fully due and owing to the undersigned from the debtor named, that no payments have been made on the account except as stated in said statement and that there is no just counterclaim or offset against the same.

I AgreeI Disagree


Provider of Services :
What type of services do you provide?
Who do we contact with any questions on your accounts?
Contact direct phone number:
Contact email address:
Contact fax number:
Where should we mail your checks?
What county does your business reside in?
Will you approve legal action?
(Legal action is requested on an individual account basis):
YesNo
If you approve legal action, who will witness if we go to court?
Do you assign account numbers to your customers?
If so, do they retain the same account number?
Or, do you assign a new account number for each date of service?
Will you permit us to report your accounts to the Credit Bureau?
If so, how long should we wait before reporting the accounts delinquent?
31 days60 days90 days
The state of Colorado allows us to add 8% interest onto any collection amounts.
This is retained by the agency and used as a negotiate tool with the consumer.
Will you allow us to add 8% interest onto your accounts?
YesNo
When do you consider your accounts delinquent?
(from the date of service):
Do you assess interest or finance charges to your accounts before they are turned to collections?
If so, please explain.
(Interest and finance charges must be agreed upon by the consumer in a signed financial agreement with your business. A signed copy of this agreement is required with each account when they are placed for collection.):
(Medical clients only)
What is your Tax ID#?
(Medical clients only)
What is your NPI#?
(Medical clients only)
Do you accept Medicaid or CICP?
How many accounts do you anticipate sending over for collections on a monthly basis?
Does the contract with your consumers allow for attorney’s fees? YesNo
Do you have any special requests or comments?



Your Account Number:
Debtor’s Name:
Debtor’s Spouse Name:
Debtor’s Social Security Number:
Debtor’s Mailing Address:
City, State, Zip:
Debtor’s Phone:
Amount:
Debtor’s Employer:
Date of Last Payment:
Date of Service:
Date of Delinquency:
Mail Returned ?  Yes No
Account Disputed ?
Other
helpful information

about debtor:
 
 
(For Example: references, nearest living relative, parents’ names
PLEASE KEEP INFORMATION FIELDS 25 CHARACTERS OR LESS)

 

To Whom Shall We Address Your Check…

Use the same information from previous contact.

 

Client Number*:
* For new clients, leave this field blank and fill in information below.
For existing clients, just fill in client number and email address field below.
Name:
Street Address:
City, State, Zip:
Phone:
Email Address:
By:
(Name of authorized representative)
For value received, I hereby assign and transfer to BC Services, Inc., a Colorado corporation, assignee our account and claim against the debtor shown above in the amount shown above, plus interest, with full authority to take whatever steps necessary to collect and satisfy the same. The undersigned warrants that the account hereby assigned is a valid debt now fully due and owing to the undersigned from the debtor named, that no payments have been made on the account except as stated in said statement and that there is no just counterclaim or offset against the same.
 I Agree I Disagree
X

Disclaimer: This communication is from a debt collector and is an attempt to collect a debt. Any information obtained will be used for that purpose.

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