Claim Information

NATIONAL LIEN & BOND
Phone: 800-432-7799
Fax: 847-432-8950

TO:

National Lien and Bond Claim Systems
440 Central Ave.
Highland Park, IL 60035

For Office Use Only:   HMB       HAE
TODAY'S DATE:

FROM:

Your Company Name:
Contact Name:
Address:
City / State / Zip: / /
Phone:
FAX:
Email:
 
General Information
  1. Type of Filing or Claim
Preliminary Notice
Collection
Enrollment of Judgment
LienClaim
U.C.C.Filing
 Joint Check
Bond Claim
Bankruptcy Preference
Other
  2. Your Contract / Payment Information:
Do you have a...
Written Contract
Verbal Contract

(Fax to: 847-432-8950 copies of
your P.O.'s, contracts, invoices,
delivery tickets, change orders,
billing statements/documents, etc.)
 Orginal contract amount:
$
Value of extras or changes:          
$
Revised Contract Subtotal
$
Less Amount Received
(the amount you have been paid)
-$
Does all extra work relate to original contract?
Yes No 		Total Balance Due
$
  3. Description of Product/Services Provided:
(Please fax all product literature to NLB at 847-432-8950 )
Did you provide:
Materials only Labor only Materials & Labor
Is your product custom manufactured for the project?
No Yes
First date of work (includes shop drawings):
Contract Date:
  4. Contract/Payment:
(Please fax copies of all notices to NLB at 847-432-8950 )
Have you issued a preliminary notice? Yes(Fax to NLB) No
Have you issued lien waiver? Yes(Fax to NLB) No
  5. Construction Type: New Rehab
Multi-Unit Residential
Personal Residence
Municipal/Government
 Subdivision
Commercial
Other
  6. Dates of Work / Furnishing / Shipping:
(Fax to NLB delivery tickets & contracts)

First:
Last:

Is there a project certificate or notice of
completion or acceptance filed?
(Fax to NLB at 847-432-8950 )
Yes No
Is the project as a whole completed?
Yes No
If Yes, Date of completion:
   7. Select Project Location:
AL
 MT
 AK
 NE
 AZ
NC
 AR
 ND
 CA
 NH
CO
 NJ
 CT
 NM
 DE
NV
 FL
 NY
 GA
 OH
HI
 OK
 IA
 OR
 ID
PA
 IL
 RI
 IN
 SC
KS
 SD
 KY
 TN
 LA
TX
 MA
 UT
 MD
 VA
ME
 VT
 MI
 WA
 MN
WI
 MO
 WV
 MS
 WY
D. C.
 CAN
 MEX
 Puerto Rico
OTHER:

Please remember to fax to NLB all documentation related to this project.
This includes contracts, invoices, notices, purchase orders, etc. FAX: 847-432-8950

 
Project Data Sheet

1. Project Name:

Address:
City/State/Zip: / /
Phone/Fax: ,
County of Property:

2. Project Owner or Public Agency:

Contact Name:
Address:
City/State/Zip: / /
Phone/Fax: ,

3. Original Contractor:

Contact Name:
Address:
City/State/Zip: / /
Phone/Fax: ,

4. Subcontractor:

Contact Name:
Address:
City/State/Zip: / /
Phone/Fax: ,

5. Is the Project:
Privately Owned Public Works Local, City or State Federal

Contract # :
Project Number # :

7. Job Info - Is there a payment bond? Yes No

If Yes, give payment bond #:
Name of bonding Company:
Contact Name:
Address:
City/State/Zip:
Phone & Fax:

9. Your Customer :

Contact Name:
Address:
City/State/Zip: / /
Phone & Fax : ,
Account #:

10. Your Order:

Value of order:
Job Number:
P.O. Number:
Contact Number:
Data Products Needed:
Approximate Start Work Date:

11. Credit Information:

Payment Terms:
Billing Cycle:
Joint Checking Direct Payment

12. Your Status in Project:

General Contractor
Subcontractor
Supplier to Subcontractor
Supplier to Supplier
Other

13. Your Document Check List:

Purchase Order / Contract
Invoices & Delivery Tickets
Copies of Waiver of Lien
Legal Description
Payment Bond
Joint Check Agreement
Preliminary Notice
Other

14. Miscellaneous Info:

 

Terms and Conditions:


I agree to the above Terms and Conditions.

Electronic Customer Signature: By submitting this claim form I agree to be bound to the above Terms and Conditions.
Date:


Please remember to fax to NLB all documentation related to this project. This includes contracts, invoices, notices, purchase orders, etc. FAX: 847-432-8950

Fax documents to NLB at 847-432-8950