Online Claim Form
* All fields marked by an asterisk are required fields with the correct format values. The form cannot be successfully submitted without the proper field values included.
Date of repair or claim submission:
Your Company Reference / Purchase Order #:
i
Service Center
Company Name:
Please type in your company zip code in this field and pick your address from the drop-down box. If your company does not appear or the address is not correct, please contact Customer Service at
1-866-888-2168
and inform them that you need to speak with a Claim Specialist.
Address:
City:
State:
Zip:
Customer
Company Name:
City:
State:
- Please select -
Distributor
Copy data from Service Center
Company Name:
City:
State:
- Please select -
Product
Model:
- Please select -
Serial #:
Show / Hide accepted serial number examples
Format
Example
Model # -- Date (4/5 digits) - Location - Assignment #
1073120 1815 R 009454
Date (4/5 digits) - Location - Assignment # -- Model #
1815 R 009454 1073120
Date (4/5 digits) - Location - Assignment #
12213 R 00358
Model Prefix Indicator - Assignment # -- printed Month/Year
85-0012345 FEB 2016
Date of Purchase:
Parts Explanation
Line Items:
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Add
Diagnostic Conclusion and Description of Repair:
i
Repair Technician:
Repair Tech. E-mail:
Repair Tech. Phone:
Upload Claim File(s):
*Max number of files allowed is 5
Accepted file extensions: .jpg, .gif, .png, .bmp, .doc, .docx, .pdf, .xls, .xlsx
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Reset
Submit button will be enabled once the Company Name is selected from the available options