The Needle Law Group - Place A Claim

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The Needle Law Group

5300 NW 33rd Avenue, Suite 206

Fort Lauderdale, Florida 33309

Toll Free 1-800-367-1174

info@needlelaw.com

Submit A Claim

We Are Aggressive, Determined & Dependable

The Rules Regulating The Florida Bar [4-1.5(f)(2)] require that a contingent fee agreement must be signed.

To submit a claim, please complete the form below and submit it to us and a client liaison will be in touch within 24 hours to discuss your matter or claim in specific detail. Should you choose to engage this firm to represent you or your company in any matter, we will forward to your attention a claim authorization/retainer agreement allowing this firm to represent your interests in this matter and explaining all terms and conditions of the representation. Before we can proceed with any claim on your behalf, we must receive the claim authorization form mentioned above and you may be required to forward to us, any additional paperwork or information necessary to effectuate your claim.

Claim Submission Form

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Please Fill In Debtor Information Here

Debtor Account # Debtor Company Contact

Address 1 Address 2

City State Zip Code

Phone Cell Phone Fax

Email Address Web Address

Information On Account To Place For Collection

Amount of Debt Age of Debt Date Last Paid

Description of Debt

Please Check All That Apply For The Account That You Wish To Place

Written Contract Oral Contract Judgment Promissory Note Loan

Short Term Note Long Term Note In-House Credit Plan

Ever placed with a collection provider previously?

Special Requirements Of Collection Provider or Additional Comments

Creditor / Your Information Goes Here

Full Name

Title

Company Name

Address 1 Address 2

City State Zip

Select The Country You Are In

Phone Fax E-mail Web Address

DISCLAIMER: The hiring of a lawyer is an important decision that should not be based solely upon advertisement. Before, you decide, please ask us to send you free written information about our qualifications and experience.

Should you choose to engage this firm to represent you or your company in any matter, we will forward to your attention a claim authorization/retainer agreement allowing this firm to represent your interests in any matter and explaining all terms and conditions of the representation. Before we can proceed with any claim on your behalf, we must receive the claim authorization form mentioned above and you may be required to forward to us, any additional paperwork or information necessary to effectuate your claim. The Rules Regulating The Florida Bar [4-1.5(f)(2)] require that contingent fee agreement must be signed. (Please Read Our Privacy Policy)

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