Warranty Claim Form

Dealer Company Name*

Warranty Claim Date:*

Month/Day/Year

Dealer Contact*

Customer Name*

Dealer Email*

Customer Contact Name*

Dealer Direct Phone*

Customer Direct Phone*

Service Order/Reference #*

Customer City/ State*

Model #*

Serial #*

Total Hours*

Start-up Date*

Month/Day/Year

Date of Failure*

Month/Day/Year

Resolution/Repair Performed*

Materials Reimbursement

*All non-PneuTech supplied parts used on warranty claim must have receipts/invoices submitted as proof of purchase.

1. Qty

1. Part Number/ Description

1. Price Ea.

2. Qty

2. Part Number/ Description

2. Price Ea.

3. Qty

3. Part Number/ Description

3. Price Ea.

4. Qty

4. Part Number/ Description

4. Price Ea.

5. Qty

5. Part Number/ Description

5. Price Ea.

6. Qty

6. Part Number/ Description

6. Price Ea.

Labor Reimbursement

@ $110.00/hr

*All non-PneuTech supplied parts used on warranty claim must have receipts/invoices submitted as proof of purchase.

Labor hours

Mileage Reimbursement

@ $1.00/mile

*All non-PneuTech supplied parts used on warranty claim must have receipts/invoices submitted as proof of purchase.

Mileage

Number of trips

PneuTech® 225 Spring Lake • Itasca, IL 60143
888-577-9664 • www.pneutech.com

All warranty claims are to be submitted to support@pneutech.com.
All warranty claim reimbursements must be authorized by PneuTech.
Reimbursement amounts are paid soley at PneuTech’s discretion.