Place a Collection Account Online
Place a Collection Account via Mail or Fax

 

 

 

 

Thank you for your business.  Please fill in the information below and simply click on Print and mail to us at:

American Adjustment Bureau, Inc.
P.O. Box 2758
Waterbury, CT 06723

Or you may fax it to us at (203) 596-8084.

We will promptly service your account.

OUR SERVICE DOESN'T COST -- 
IT PAYS!

Please send our Check to:

Name:
Address:
City:
State:
Zip:
By:
(Name of Authorized Representative)
Date:
Phone:
Email:

Debtor Information

Debtor First Name:    Initial 
Debtor Last Name:
Address:
City:
State:
Zip:
Was Mail Returned?  Yes   No
Debtor Home Phone:
Debtor Work Phone: Ext:
Debtor Employer:
Debtor Employer Address:
Debtor Social Security Number:
Date of Birth:
Marital Status:
Bank Account Name:
Spouse's Name:
Spouse's Work Phone #: Ext.
Spouse's Employer:
Spouse's Employer's Address
Spouse's Social Security Number
Date of Birth:

Patient Information
(If Patient is the same as Guarantor, skip to Account Information)
Patient First Name:    Initial 
Patient Last Name:
Patient's Social Security Number
Date of Birth:
Relationship to Above:
Account Number   

Account Information
Date of Last Charge:
Date of Last Payment:
Principal Amount Due:

Miscellaneous Information
Is Guarantor a Home Owner?: Yes   No
If yes, location. 
Nearest Relative:
Is this the insurance balance? Yes   No
If not, Insurance Company Name:
Was the account: Self Pay   Workers Comp 
MVA   Liability Case 
Comments: