File a Warranty Claim

When filing a claim, maximum travel hours and maximum travel miles are the maximum allowed for each trip. If more than one trip is required, more miles can be claimed. To claim additional mileage, indicate the number of trips made in the comments section.

"*" indicates required fields

Claim Number

Distributor

Company

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Account Number

Person Filing Claim

Name

First Last

Facility

Facility Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Product Information

Model Number*

Pre-Authorization Number*

Application*

System Type*

Problem*

Serial Number*

Please enter FULL serial number (including the date)

Startup Date*

Run Hours*

Room Conditions*

Claim Information

Date of Repair*

Defective Parts

Max PSI or IN of HG

Description of Problem*

Warranty Work Performed*

Parts Used

Item #

Description

Invoice #

Quantity

Price

Please enter a number from 0 to 9999999.

Price

Please enter a number from 0 to 9999999.

Price

Please enter a number from 0 to 9999999.

Price

Please enter a number from 0 to 9999999.

Price

Please enter a number from 0 to 9999999.

Price

Please enter a number from 0 to 9999999.

Sub-Total

Parts Total

Claim Pricing Information

Package Purchased from*

Travel Mileage Rate

Hourly Rate

On-Site Hours

Please enter a number from 0 to 9999999.

Enter time in hours rounded to the quarter hour (.00, .25, .5, .75)

On-Site Hours Total

Travel Hours

Please enter a number from 0 to 9999999.

Enter time in hours rounded to the quarter hour (.00, .25, .5, .75)

Travel Hours Total

Travel Miles

Please enter a number from 0 to 9999999.

Max 200 per trip

Travel Miles Total

Toll Road Fees

Please enter a number from 0 to 9999999.

Claim Total

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Comments

This field is for validation purposes and should be left unchanged.