Please provide the following contact information.
Dealer Name*
Contact*
Phone*
Fax
Email*
Dealer Claim Number 
Please provide the following contact information.
Owner's Name*
Contact*
Address*
 
City*
Postal Code *
Phone
Please provide the following product information.
Product Name*
Miscellaneous Product:
Model*
Serial No.*
Hour Meter Reading* 
Purchase Date*
Failure Date*
Repair Date*
Conditions Found. Cause of Failure.*
Repair Made.*
Labour Claimed  @ $ per hour
Parts used to make repair
1. Part# Qty Description
2. Part# Qty Description
3. Part# Qty Description
4. Part# Qty Description
5. Part# Qty Description
Collapse/Expand  Additional Parts: 6-10 parts
6. Part# Qty Description
7. Part# Qty Description
8. Part# Qty Description
9. Part# Qty Description
10. Part# Qty Description
Collapse/Expand  Additional Parts: 11-15 parts
11. Part# Qty Description
12. Part# Qty Description
13. Part# Qty Description
14. Part# Qty Description
15. Part# Qty Description
Collapse/Expand  Additional Parts: 16-20 parts
16. Part# Qty Description
17. Part# Qty Description
18. Part# Qty Description
19. Part# Qty Description
20. Part# Qty Description
Note: Claim must be returned within 10 days of repair, so that a claim can be filed on your behalf. All parts should be retained until credit is received in the event that the manufacturer requires them returned.