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Lien Assurance Placement Form

Your Name:
Company Name:
Street Address:
City:
State:
Zip-Code:
E-Mail:
Phone:
Your account name:
Your account number:
Amount of claim:
Job Type: Public
Private

Project Information

Job site name:
Street Address:
City:
State:
Zip-Code:
 
Owner:
Street Address:
City:
State:
Zip-Code:
 
General Contractor:
Street Address:
City:
State:
Zip-Code:
 
Sub-Contractor:
Street Address:
City:
State:
Zip-Code:

If the job is bonded? If yes please e-mail bond to vingold@commercialcollection.com or fax to 800-873-5211.

If you have notice of commencement, please e-mail to vingold@commercialcollection.com or fax to 800-873-5211. (if applicable)

If the lien waiver is asked for, please e-mail to vingold@commercialcollection.com or fax to 800-873-5211. (if applicable)

Sales Information

Project manager name:
First delivery date:
Last delivery date:

Action To Be Taken
(choose all that apply)

    File lien (fax or e-mail invoices/statements)
    Send pre-lien Notice
    Obtain copy of bond and verify coverage
    Investigate lien potential
    File bond claim
    Tracking

Additional Comments


If you have any questions at all, do not hesitate to call Valerie Ingold at 800-873-5212 ext 256 or e-mail vingold@commercialcollection.com.

Disclaimer of Liability

It is understood and agreed that CCC of New York wil use its best efforts to serve or file the above requested document and that CCC of NY is providing its services through sources it deems to be reliable. CCC of NY shall not be responsible or liable for claims for damages for any reason whatsoever, including claims for special, punitive, incidental or consequential damages, or claims for lost profit.


Strategic Outsource Solutions (SOS)
is a Division of Commercial Collection Corp of NY
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