Warranty Claim Form

Machine Information

Name

First Last

Phone

Email*

Serial Number*

Date of Repair*

Model Number*

Hour Meter

Service Call Address*

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

Dealer Information

Dealer*

Customer Invoice or Claim #*

Branch Location (City, State)*

Phone #

Details

Detail of Failure*

Detail of Correction*

Parts Used

Parts

Item Part #

Qty

Part Description

Cost Each

MEC Invoice #

Charges

Labor Hours

Travel Hours

Other

NOTE: Freight charges to inlcude parts return freight and will not be reimbursed
MEC labor rate is $95.00 per hour
**Travel reimbursement is $95.00 an hour up to 3 hours max.

*Required Field

Total Parts

Total Labor

Total Travel

Total Credit (U.S. Dollar)

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Comments

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