Claim #

                 Hit Counter 

Distributor Information: E-Mail 

 

Name Account Date
Address City St

 

 

Dealer Information: E-Mail 

 

Name Telephone

 

Address City St

 

Installer Information: E-Mail 

 

Product Information:  
Name Telephone
Address City St

 

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)

 

 

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

(All italicized areas shown above must be completed by Distributor / Dealer in order to complete claim analysis.)
Date Received   Received By  

 

Evaluation Results
Quantity within Specifications   Quantity not within Specifications  

 

 

 

 

-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