Warranty Form - Curtis Industries

Section 1: Dealer / Purchase History

Dealer #: *

Order/Invoice # *

Date *

Dealer Name: *

Address *

City *

State/Provence *

Zip/Postal Code *

Country *

Customer/End User Name:

Address

City

State/Provence

Zip/Postal Code

Country

Section 2: Equipment Information

Curtis Part Number: *

Serial # / MFG Code: *

Date of Installation: *

Date of Failure: *

Vehicle Make & Model: *

Vehicle Hours *

Date of Repair: *

Detailed Description of failure / reason for credit request / attach copies of invoices *

Upload file

Section 3: Repair Information

List All Parts Replaced:Click on Add Part for each additional Part to be listed.

QTY: *

Part #: *

Return Part? *YesNo

Amount: *

Description *

Warranty Labor

Description of Work Performed *

Repair Code *

Hours *

Total *

Total Labor Allowance *

Other CreditsExplain & Attached Receipts for “Other Credits”

Upload file

Totals

Total Parts: *

Total Labor & Other Credits *

Total Credit Requested: *

Parts to be returned via: *UPSCommercial CarrierCustomer Drop-Off

Dealer Signature *

Save as Draft

Warranty Claim Form

Section 1: Dealer / Purchase History