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Customer email
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Customer name
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Form completed by
Myself - customer
Service Provider
Failure Problem
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Claim Category
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Please Select
Heating and Air Conditioning
Electrical
Plumbing
Appliances
Miscellaneous
Product
Furnace, sink, dryer, etc.
Manufacturer - original unit
Model - original unit
Serial Number - original unit
Equipment Age - original unit
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Manufacturer - replacement unit
Model - replacement unit
Serial Number - replacement unit
Parts Cost
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Labor Cost
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Total Cost
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Service Provider Name
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Service Provider Phone
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Service Provider Address
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Service Provider License #
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Receipt/Invoice
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Please upload any receipts/invoices related to your claim
Supporting Docs and Photos
Please add any additional photos, video, or documents you may have concerning the service/issue.
I understand I must upload a detailed receipt or invoice including provider's name, address, phone number and license number, model and serial number in order to review and approve my claim.
I Agree
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Submit