Vortexx Warranty Claim Form - Tab | Vortexx Pressure Washers

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Distributor*

Submitted By:*

First

Last

Dealer Information

Dealer Name*

Dealer Email*

Dealer Address*

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

Customer Information

Customer Name*

First

Last

Customer Email

Customer Address*

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

Equipment Information

Equipment Model*

Serial #*

Purchase Date*

Fail Date*

Repair Date*

Labor Information

Cause of Failure*

Posted Shop Labor Rate*

Labor Time*

Work Performed*

Were new parts required to do this work?*

Yes
No

Parts

Part Number (1)*

Description (1)*

Quantity (1)*

Dealer Cost (1)*

Please list cost for one (1) part

Part Number (2)

Description (2)

Quantity (2)

Dealer Cost (2)

Please list cost for one (1) part

Part Number (3)

Description (3)

Quantity (3)

Dealer Cost (3)

Please list cost for one (1) part

Part Number (4)

Description (4)

Quantity (4)

Dealer Cost (4)

Please list cost for one (1) part

Misc

Miscellaneous

Please list any other costs or information here

Reference/Claim Number

If you have your own reference or claim number for this claim, please enter it here.

Cost

Total Labor Cost

Total Parts Cost

Total Cost