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Arbitration & Claim Submission Form
Credit Card Processing Info
Do you currently have an active account?
How long have you been processing for?
What company are you processing with?
FiServ / FirstData / CardConnect
Have you ever had a processor terminate your account?
Reason for termination?
How do you accept payments
Our Website / Ecommerce
In-Store Physical Terminal
In-Store POS System
Mobile Phone / Device
3rd Party Software
Over the Phone
Describe your payment acceptance process
What software, system or hardware do you use to process credit card?
What payment do you currently accept?
Visa / MasterCard
Debit / PIN
eCheck / ACH
What is the total company revenue?
This should include all sales including those outside of credit card processing
What is the total processing revenue?
Average credit card transaction size
Highest credit card transaction size
Estimated monthly volume average
Is your business seasonal?
What are your highest volume month(s)?
Contract & Statements
Upload a copy of your contract and most recent statements
Drop files here or
Max. file size: 50 MB.
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