Contact Us

5301 E. State St.
Suite 316A
Rockford, IL 61108

TOLL FREE: 1-800-251-3357
Sales Department: 630-761-8400 ext. 230
FAX: 815-997-1600

e-mail:
 info@weissandmueller.com

Claim Form
All fees are strictly contingent upon collection.

* denotes optional field

CLIENT INFORMATION
Company Name:
Contact Name:
Address:
City:
State:       Zip Code:
Country:
Phone 1:   * Phone 2:
* E-Mail:
Fax:
DEBTOR INFORMATION
Name of Account:
* Responsible Owner/Officer/Party:
Address:
City:
State:       Zip Code:
Country:
Phone 1:     Phone 2:
* E-Mail:
* Fax:
Account # :
*Balance Due:
Date of Last Transaction:
   
Documentation to Follow
(copies only - please do not send originals)
 

Will Receive By:

 Mail      Fax
  Invoice(s) Original Contract
  Credit Application COD NSF Check
  Itemized Statement Open Account NSF Check
 
Additional Information: