Warranty Claim Form

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Warranty Claim Form

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Distributor Name*
Distributor Name if not listed
Distributor Email*
Distributor Phone Number
Technician Name*
First Last

Owner Information
Company (End User Name)*
Contact Name*
First Last
Street Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number*
Email*

Compressor Information
Compressor Model*
Compressor Part Number*
Compressor Serial Number*
Pump Serial Number
Pump Serial Number (Duplex Units)
Date of Purchase*
Date Format: MM slash DD slash YYYY
Date of Start Up*
Date Format: MM slash DD slash YYYY
Was this compressor started up by an authorized FS-Curtis Distributor?*
- Yes
- No
Industry*
Describe if necessary

Trip 1
Date*
Date Format: MM slash DD slash YYYY
Travel Hours*
Mileage*
Labor Hours*
Defect Description*
Trip 2
Date
Date Format: MM slash DD slash YYYY
Travel Hours
Mileage
Labor Hours
*Any additional trips require pre-approval from the FS-Curtis warranty department.
Corrective Action Taken*
Components Used (List Quantity, Description of Part(s), Part No(s)., and Cost)
Freight Charges*
FS-Curtis Invoice Number or Distributor Purchase Order Number for repair components purchased:
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Comments
This field is for validation purposes and should be left unchanged.