New Client Intake Form Contact Name Contact Title Contact Email Contact Phone Company Name Please provide your official corporate name or DBA. Company Website http://www. Company Address Authorized Signer Authorized Signer Title Authorized Signer Email How did you hear about us? Please SelectGoogleLinkedInReferralOther If referred, please let us know by who so we can thank them. Have you worked with a collection agency before? YesNo If yes, please describe your past experience with your previous collection agency. Please describe what you liked and didn't like. Do you have a standard process for granting credit? YesNo Do you have a standard process for managing your receivables and escalating past due accounts? YesNo Are you open to feedback to improve your credit granting and internal receivables management processes? YesNo What type of debt will you assign? Please select all that apply. CommercialConsumerMedical How many accounts per month do you expect to assign to collections? This is the amount of accounts you expect to assign on a monthly basis, excluding any backlog of old accounts. Please Select1-1011-5051-100101+ What is the average dollar balance of your accounts? This is calculated by taking the total dollar amount of bad debt and dividing it by the number of bad debt accounts. Please Select$100-300$$301-1000$$1001-5000$$5001-10000$$10001$+ At what age (from last date of service) do you expect to escalate your accounts to our collection agency? Please Select1-3 months3-8 months9-12 months12+ months What documentation do you gather from your customers prior to doing business with them? Client intake sheet (standard form to gather client information)Credit applicationService AgreementNone What do you do internally to try and collect your past-due receivables? Past-due noticesEmailsText messagesAutomated messages (dialer)Internal collection calls (calls made by your staff) Do you accrue interest on your past-due accounts? YesNo Would you like us to credit report your accounts? YesNo What else would you like to share with us? Form Completed By: Recommended agreement: Please SelectConsumer AgreementCommercial AgreementMedical/Dental AgreementCustom Agreement If custom please describe:
