Online Debt Submission | Prushka Fast Debt Recovery

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| Online Debt Submission

Prushka Online Action Form
If you hate forms, call us on 1800 641 617 and we will gladly take your debt details on the phone. You only need to complete your details once.
Step1: Complete details Step2: Acknowledge our trading terms Step3: Submit *Compulsory Fields
Are you a: *
Debtor: *
Your Email Address: *

YOUR DETAILS > EXISTING CLIENT
Prushka Client Reference Code:
Name/Trading Name: *
State:
Suburb: *

YOUR DETAILS > NEW CLIENT
Name/Trading Name: *
Postal Address: *
Suburb: *
State: *
Postcode: *
Contact Name: *
Telephone: Leave no spaces (e.g. 98745000)
Fax:
Mobile:
Nature of Business: *
ABN:

PARTICULARS OF THE BUSINESS WHICH OWES YOU MONEY
Business Name:*
Trading Name (if different):
ABN:
Contact FirstName:
Contact Surname:*
Gender:
Email:
Postal Address: *
Suburb: *
State:
Postcode: *
Telephone: Leave no spaces (e.g. 98745000)
Fax:
Mobile: Leave no spaces (e.g. 0400058004)

PARTICULARS OF THE PERSON WHO OWES YOU MONEY
Gender:
First Name:*
Last Name:*
Home Address: *
Suburb: *
State:
Postcode: *
Email:
Telephone: Leave no spaces (e.g. 98745000)
Fax:
Mobile: Leave no spaces (e.g. 0400058004)
Work Details:
Name of Relation:
Phone Number of Relation:

FOR WORKCARE OR MOTOR ACCIDENT BOARD CLAIMS
Claim Number:
Date of Accident:
Name and Address of Patient's Employer:
State:
Postcode:
Insurer:

Add Prushka Commission to the Debt? * It is easy to get your bad payers to pay collection costs.	(Only select an option that your trading terms allow you to select. If you are not sure please call Client Services Team on 1800 641 617 to find out more.)
Please Note: For Prushka Commission cannot be added to the Workcover or Motor Accident Board Claim.

MONIES OWING
Date of first invoice: *
Balance Owing: *	$
Details of service or goods provided by you: *
Add Prushka Commission to the Debt? *	(Only select option if your trading terms allow you to do so. Call Client Services Team to explain further)

OTHER INFORMATION
Comment:

Do you have an Attachment? *	Yes No
Do you have an Attachment? *	Please Note: To assist with collection, we need a copy of the invoice for the debt.
Please attach any relevant Information:	Please Note: Please limit to a file size of maximum 1MB with 4 attachments
I confirm that the above details are true and correct and that I agree to be bound by Prushka's Terms and Conditions.
Date:	17/01/2019
Name: *	Typing your name above constitutes your signature
Position: *	State Position if Signing on behalf of a business

Please type what you see:

Enquiries - Call the Prushka Client Services Team - Freecall 1800 641 617
One Form only. After you have submitted this form, you don't need to complete forms for other debts. Just email, fax or post copies of all other overdue accounts to us. Post: Private Bag 6, Mitcham, Victoria, Australia 3132 Email: info@prushka.com.au Fax: (03) 9872 4757