Warranty Claim Form (Rotary, Recip, Scroll) - FS-Curtis

Warranty Claim Form (Rotary, Recip, Scroll)

Home|Warranty Claim Form (Rotary, Recip, Scroll)

Warranty Claim Form

Step 1 of 5

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
Company Email*
Street Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Compressor Information
Compressor Serial Number*
Date of Start Up*
MM slash DD slash YYYY
Date of Warranty Failure*
MM slash DD slash YYYY
Date of Warranty Completion*
MM slash DD slash YYYY

Please describe your typical hours of operation:
Compressor Type*
Total Hours*

Pump Hours

1	2	3	4

Load Hours*

Line Voltage (Static):

L1/L2	L2/L3	L1/L3

Line Voltage (Max Press.):

L1/L2	L2/L3	L1/L3

Full Load Amps (Max Press.):

L1	L2	L3

Unload Amps:

L1	L2	L3

Control Voltage

Pressure Settings:

Load	Unload

Pressure Settings:

Cut in	Cut out

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Duty Cycle	Run Time	Off Time

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Duty Cycle	Modulation

Ambient Temperature

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Ambient Temperature:	Air/Oil Temp. at Full Load:

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Separator DP:	Lubricant used:

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System Air Receiver Size:	Gallons:

Lubricant Used

Complaint*
Cause (Be Specific)*
Corrective Action Taken*
Trip 1
Date*
MM slash DD slash YYYY
Travel Hours*
Mileage*
Labor Hours*
Trip 2
Date
MM slash DD slash YYYY
Travel Hours
Mileage
Labor Hours
*Any additional trips require pre-approval from the FS-Curtis warranty department.
Components Used (List Quantity, Description of Part(s), Part No(s)., and Cost)

Components Used*

QTY	Description	Part Number	Cost

Click the plus sign to add more parts

Freight Charges*
FS-Curtis Invoice Number or Distributor Purchase Order Number for repair components purchased:
Comments
This field is for validation purposes and should be left unchanged.