Single Placement Form
Individual claims can be submitted online using the form below or simply e-mail them to newclaims@agaltd.com. If you have any questions on claim submission please be sure to contact us at (631) 719-8027.

CREDITOR INFORMATION

Address
Address 1
Address 2
City
State/Province
Zip/Postal
Country

DEBTOR INFORMATION

Address
Address 1
Address 2
City
State/Province
Zip/Postal
Country

PLACEMENT DETAIL

DOCUMENTATION

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.

Maximum file size: 10MB

You may attach up to 5 files (10MB each) to this submission.
Acceptable file formats include MS Word/Excel, Apple Pages/Numbers, PDF and Zip files.