Placements

List an account now by filling in the form below. 

If you would like access to our client portal please email: ccbclientservices@ccbinet.com. We will then set you up with secure access to Client View. You can manually turn over accounts, verify balances, and report payments!

You can also download a listing sheet to print out and mail in to our Bismarck office.

Single Listing Sheet (.pdf)
Requires Acrobat Reader

Information Pertaining to Your Business

Submitted By (your business name)^*

(your business name)

Send correspondence to (person's name)^*

(person's name)

Address

City

State Please SelectAlaskaAlabamaArkansasArizonaCaliforniaColoradoConneticutWashington DCDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyoming

Zip Code

Phone

Fax

Date

Email

CCB Client Number

(if known)

Type of Collection^* Please SelectDirect ActionPre-Collection

Consumer Information

Name^*

Spouse's Name

Address^*

(last known)

Address 2

City^*

State^* Please SelectAlaskaAlabamaArkansasArizonaCaliforniaColoradoConneticutWashington DCDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyoming

Zip^*

Phone

Cell Phone #

Date Of Birth

Social Security

Driver's License #

Employer

Employer Address

Employer City, State, Zip

Employer's Phone

Spouse's Information

Spouse's Employer

Spouse Employer Address

Spouse's Employer City, State, Zip

Spouse's Employer's Phone

Spouse's Social Security

Spouse's Date Of Birth

Spouse Cell Phone #

Account Information

Your Account Number For Consumer^*

Date Interest Figured To

Date of Service / Transaction Date^*

Principle Balance At Date Of Service

Payments Made^*

Credits / Adjustments^*

Additional Fees^*

(Miscellaneous charges)

Interest^*

Current Placement Amount^*

Date of last charge

Date of last payment

Insurance Information

(if Healthcare account please fill out)

Name on Insurance Card

Insurance Company

Policy #

Group #

Next of Kin Information

Next of Kin Name

Next of Kin Address

Next of Kin City, State, Zip

Next of Kin Phone #

Relationship to

Patient Information

Patient Name

Patient Date Of Birth

Patient Soc. Sec. #

Additional info

(such as references or if account is in judgement)

This account is assigned to you with full power and authority to perform all acts necessary for the collection and settlement of said account.