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Claim Type
*
Claim Date
*
P/O Num
Distributor Information
Name
Address
*
City / State / Post Code
Country
Phone
Contractor / Installer Information
Customer / Homeowner Information
Name
Address
City / State / Post Code
Country
Phone
Shipping Address for Replacement
Company
Contact
Address
City / State / Post Code
Country
Phone
Company
Contact
Address
City / State / Post Code
Country
Phone
Equip Type
*
Error Code
Model #
*
Did your heat pump have power at the time of failure?
*
Is tank leaking?
Serial #
*
Have all items in the Check List in the Installation Manual been checked?
Install Date
*
Are water pipes connected correctly? Water
filter clean? System pressure below 95 psi?
Do you certify that this system has been properly serviced?
Problem Description*
* Required Fields
Part Name
Quantity
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