Request A Receipt

If you have made a payment and would like us to email you a receipt let us know by completing the form below. Please note that receipts for check payments will take a minimum of 14 days to process.

1. General Account Information
Please include Diversified's eight-digit account number on your statement.
Account Number*
Creditor*
First Name*
Last Name*
Address*
City*
State*
Zip*
2. Phone and Email Disclaimer
Phone
Email*
Email Disclaimer*
You agree that Diversified Adjustment Service, Inc. may from time to time make calls and/or send text messages to you at any telephone number associated with your account, including wireless telephone numbers that could result in charges to you. You hereby confirm that any number you provide belongs to you. The manner in which these calls or text messages are made to you may include, but is not limited to, the use of prerecorded/artificial voice messages and/or automatic telephone dialing system. You further agree that Diversified Adjustment Service, Inc. may send e-mails to you at any e-mail address you provide us or use other electronic means of communication to the extent permitted by law. You agree and acknowledge that any e-mail address or any other electronic address that you provide is your private address and is not accessible to unauthorized third parties. You agree and acknowledge that you have requested that we send the document(s) you have requested to you at the e-mail address you have provided. Consent may be revoked at any time and by any reasonable means.
- I Acknowledge and Agree
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IMPORTANT

Request a Receipt

Request a Receipt

1. General Account Information

2. Phone and Email Disclaimer

Contact Diversified for a secure solution to your collection needs.