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Form Number: 1655
IMPORTANT
1. Claim must be Submitted Within 30 Days of Failure.
2. Fill out One Claim Form for Each Unit.
3. Hold Parts at Dealer for Disposition Instructions.
Date:
Filled Out By:
Dealer Account Number:
Contact Email:
Customer Info
Dealer Info
Customer Name:
Dealer Name:
Address:
Address:
City:
City:
State
State:
Zip
Zip:
BASE UNIT OR ATTACHMENT THAT FAILED
Model:
Serial No:
Date of Purchase:
Date of Failure:
Acres/Hrs Operated:
Tractor Make & Model:
Date of Repair:
Attachments Added:
DESCRIPTION OF FAILURE/REASON FOR CREDIT (DO NOT SAY DEFECTIVE).
Dealer Signature:
By checking this box the dealer verifies the above information.
PARTS PREPLACED (ITEMS CHECKED MUST BE RETURNED TO FACTORY).
Quantity:
Part No:
Description:
Warranty Labor
Hours/Description
Rate
Total
Total Labor Allowance
Explain & Attach Receipts for "Other Credits"
Other Credits
Total
PRODUCTS
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RESOURCES
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COMPANY
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LEGAL
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CONTACT US
10784 Industrial Parkway Marysville, OH 43040
Tel: 614-873-4620 Fax: 614-873-8584
