KMA - New Account Setup

To set up your account with KMA, please complete and return this form. Upon receipt we will set up and activate your account with KMA. A representative will contact you to discuss your account and claim placement process.

Please provide the following information (* denotes required fields):

Your Company Name*:
Street Address*:
Address (cont.):
City*:
State/Province*:
Zip/Postal Code*:
Primary Contact Name*:
Primary Contact Phone*:
Primary Contact Fax:
E-mail:
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Your Company's industry, product, or service:



Where are your delinquent accounts?

    Local Regional National International

Who are your customers?

    Consumers Retail Commercial / Business

What is the average balance past due for your accounts?    $

When do you consider a delinquent account a problem?

    1 month 2 months 2 months 4 months 5+ months

When do you charge off debt?

    1-2 months 3 months 4 months 5 months 6+ months

Approximately how many accounts per month are A/R problems?

    1-10 11-25 26-50 51-100 101+

Please indicate chargeable fees allowed by contract/agreement with your client:

Collection / Legal Costs Specify Amount: $

Late Specify Amount: $

Finance / Interest Specify Amount: $

Returned Check Specify Amount: $