ORDER FOR DEBT COLLECTION AND CALLING IN OF CLAIMS

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ORDER FOR DEBT COLLECTION AND CALLING IN OF CLAIMS
ORDER FOR DEBT COLLECTION AND CALLING IN OF CLAIMS
Information on debtor
Information on creditor/client
(please fill in as completely as possible and avoid PO box addresses)
Name and address: Name and address: Represented by: Country: Telephone: Contact: (if other than Germany):
Fax: Your Debtor Customer No: Telephone: Your bank account (incl. IBAN & BIC):
Fax: (only necessary with 1st application)
Other contact information (e-mail, homepage) Coface Insurance No.:
(only necessary with 1st order)
Claim (if if more than one invoice, please attach an outstanding balance list or invoice copies)
Sum: Currency:
Date of invoice: Reason for claim (e. g. delivery of goods): Due date: Enforcement fees: Retention:
yes
no
Debt is insured with Compagnie Française d’Assurance pour le Commerce Extérieur SA,
Niederlassung in Deutschland (Coface)
yes
no
Debt is credit insured by another company yes
no
(please state your insurance company) The provisions of the Debt Collection Agreement and the General Trading Conditions for Debt Collection are expressly
accepted.
CDM-9113-1/08-16
Place/Date Stamp/Signature COFACE DEBITORENMANAGEMENT GMBH – ISAAC-FULDA-ALLEE 1 – 55124 MAINZ – POSTFACH 1209 – 55002 MAINZ – www.coface.de
T. +49 (0) 61 31 / 60 04-0 – F. +49 (0) 61 31 / 323-70 961 – AMTSGERICHT MAINZ HRB 40170 – STEUERNUMMER: 26/652/03076 – UST.-ID-NR.: DE111612309
GESCHÄFTSFÜHRUNG: TÉVA PERREAU – ALEXANDER KRAUS – SITZ: MAINZ – REGISTRIERTER INKASSODIENSTLEISTER NACH § 10 ABS. 1 NR. 1 RDG
MITGLIED IM BUNDESVERBAND DEUTSCHER INKASSO-UNTERNEHMEN E.V.
COMMERZBANK AG, MAINZ – BLZ 550 400 22 – NR. 200 116 200 – IBAN: DE68 5504 0022 0200 1162 00 – BIC: COBA DE FF

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