303 660 0111
Toll Free 888 355 4800
Company Name Address City Select a State Alaska Alabama Arkansas Arizona California Colorado Connecticut Washington D.C. Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missourri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming State Zip Code Phone Number Fax Number Federal Tax ID No. Contact Person Title Contact Person's Email Address Contact Person's Mobile Phone No. Please list the principals/owners/shareholders/equity holders: Name Soc. Sec./Fed. Tax ID Name Soc. Sec./Fed. Tax ID Name Soc. Sec./Fed. Tax ID Name Soc. Sec./Fed. Tax ID
How long has the company been in business? Does the company operate under any other names or dbas? Please provide us with a brief overview of your company and its history. How did you hear about CarePoint Financial? Why are you selling your portfolio? What are the total gross charges of your annual LOP/Lien revenue? What percentage of your entire business is LOP/Lien work? Have you made other attempts in the past to sell your portfolio? Yes No If yes, to whom? Why didn't you proceed at that time?
Has your company or any of its principals: Been the subject of any bankruptcy proceedings? Yes No If yes, please explain. Been questioned or investigated by any law enforcement or government agencies? Yes No If yes, please explain. Been defendant/s in any lawsuits? Yes No If yes, please explain. Are there any claims, actions, suits or judgments pending against the company? Yes No If yes, please explain. What percentage of your entire business is LOP/Lien work?
Type of receivables: Workers Comp Personal Injury Subcategory: Diagnostic Therapy/Chiropractic Surgical Other If other, please explain in detail. Gross Amount of Portfolio Number of Cases in Portfolio Average Age of Cases in Portfolio Is portfolio currently being managed by a collection company? Yes No If yes, who is the collection company, and what is their contact information. Have you informed the collection company of your decision to sell your portfolio? Yes No Are you contractually obligated to the collection company until the receivables have been collected? Yes No Would there be a termination fee? Yes No If yes, how much? If no, what is your current process for collecting on these cases? Please explain in detail. How often are these cases being statused to verify their validity? Do all liens/LOPs have both patient and attorney signatures? Yes No Patient Signatures Only: % Attorney Signatures Only: %
Can you provide us with a detailed collection history? Yes No If yes, for how long? If no, please explain. What percentage of these patients are still under treatment? % Are there any UCC1 liens or encumbrances on the receivables? Yes No If yes, will you be able to obtain a release? Yes No Explain: Please tell us of any other information you think might be helpful in evaluating your portfolio:
Please review all information before clicking below to submit your application.
