Claim #

Hit Counter                  

Distributor Information:

E-Mail:   
Name:
Account:
Address:
Date:
City:
St:




 

Dealer Information:

E-Mail:       
Name:
Telephone:
St:
City:
Address:




 

Installer Information:

E-Mail:       
Name:
Telephone:
St:
Address:
City:




 

Product Information:

Part Number:
Qty:
Product Serial #:
Description:
Date Install:
Date Failed:
Dlr/Install Inv#:
Inv Date:
Dlr/Install Claim Ref#:
Engine Code:
Miles/Hrs:
Claim Preparer:
Complaint, Cause, Correction:

Attach All Supporting Documentation - (Please Make Copies of this Report for your records as Needed)

(All highlighted areas require information before this form is finalized. Please contact Customer Service at 877-658-3938 should there be any questions or issues with this form.)

Quality Control Product Inspection Summary - This Section is used by the Inspection Department

Date Received:
Received By:
Quantity within Specifications:
Quantity not within Specifications:
Evaluation Results:
-Warranty Accepted, Replacement'(s) Sent to distributor at No Charge Qty
-Warranty Accepted, Full Credit Issued to Distributor Qty
-Warranty Denied, _____ Cores Returned or _____ Core Credit Issued to Distributor Qty
Invoice #:
Invoice Date:
Completed By:
Please Return Units and Form to ProDiesel Warranty Department - 318 Fesslers Lane - Nashville, TN 37210