MAILING ADDRESS

AG Adjustments
PO Box 9090
Melville, NY 11747

TELEPHONE

Phone: (631) 425-8800
Fax: (631) 425-8808
Toll Free: (888) 496-1600

Placement Form

You can submit multiple claims by putting the claim information in an Excel spreadsheet (click here to download a sample) then upload and submit below. Supporting documents may also be uploaded and submitted using this form. Please supply enough information so we know which claim your follow up documents correlate to.

If you have any questions on claim submission please be sure to contact us at (631) 719-8028.

(Fields marked with * are required)

Today's Date:	05/18/2012
Assigned by (name of creditor): *
Your name: *
Your e-mail:
Reference Number:
Comments:

Please submit any contracts, notes, returned checks, itemized statements or other papers that are needed. When necessary, you are authorized to forward this account, under bond, to a commercial attorney.
File Upload: (20 megabyte maximum each file)
Files Attached: 0