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Firm Name 

Firm Location 

Bar License: Malpractice Insurance:
Type of Firm:  Contact: 
Toll Free #:  Email:
Phone #:  Fax #:  
Web Address:  Firm Founded: 
# of Office Locations:  # of Employees: 
Service States:  Service Cities/Counties: 
Associations:  Receivables Collected: 
Specialize In:  Collection Fee Structure:
Commercial Recovery Rate %:  Retail Recovery Rate %: 
Acknowledgement Sent:  Status Report Sent: 
Remittance Report Sent:  Report Credit To: 
Client Agreement: Cancellation Clause: 
Upfront Suit Fees: Contingency Increase For Suit: 
Additional Services Offered:  Firm Comments:

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