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WARRANTY CLAIM / INITIAL QUALITY REPORT FORM
*indicates required fields
*Person completing this form :  
*Email :  
*Status update notifications related to this
form will be emailed to this address

* Please select one :
 
Machine Information
* Machine SAP# :
(First 8 digits in serial #)
 
 
* Machine Complete Serial# :  
* Date Code (XXXX) :
(4 digits located on serial plate under bar code)
 
 
* Sales Order # or Invoice# :  (PO # is not accepted)
* Machine Sold Date :  
* Repair Date :  
Service Center Information
* Service Center :  
* Customer#:  
* Address :  
* City :  
* State / Province :  
* Zip / Postal Code :  
* Phone :  
* Fax :  
* Email :    
Customer Information
* Customer Name :  
* Attention :  
* Address :  
* City :  
* State / Province :  
* Zip / Postal Code :  
* Phone :  
Claim Details & Job Information
* Description Of Failure, Including All Relevant Part Numbers (please fill out for IQR / Warranty Claim) :  

Warranty / IQR Information

Part#Defect CodeDescriptionQty.Dealer Cost
          $ Ea    
    Add New Row Remove Row
Labor Ops Number Labor Description Labor Hrs. Labor Rate
0303 Labor   $60 per hr.
Travel Ops Number Travel Description Travel Hrs. Travel Rate
0301 Travel (Stationary Equipment Only)   $60 per hr.
Diagnostics & Admin Ops Number Diagnostics & Admin Description Diagnostics & Admin Hrs. Diagnostics & Admin Rate
0302 Diagnostics & Admin   $60 per hr.
    Freight $  
General Issues (check all that apply)
Shipping: Customer Service: Manufacturing: Engineering: Warranty:








Accounting:
















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