Parts Only Claim Submission
( Items with red asterisk are required )
Parts Claim Information
EIA Manufacturer ID:
Reference/Claim Number:
Account Number:
*
Brand:
*
Please select
Whirlpool
Thermador
Speed Queen
L.G.
Samsung
Bosch
Dacor
Frigidaire
G.E.
Jenn Air
Kenmore
Maytag
Fisher Paykel
Uline
Model Number:
*
Serial Number:
*
Customer First Name:
*
Customer Last Name:
*
Customer Address Line1:
*
Customer Address Line 2:
Customer City:
*
Customer State:
*
Please select
Alaska (AK)
Alabama (AL)
Arkansas (AR)
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West Virginia (WV)
Wyoming (WY)
Guam (GU)
Amer. Samoa (AS)
Fed. Micronesia (FM)
N. Mariana Is. (MP)
Marshall Is. (MH)
Palau (PW)
Customer Country:
Customer Zip:
*
Servicer's Email:
*
Customer Phone:
*
(no dashes)
Date Part(s) Installed
*
Date Part(s) Failed
*
Customer Complaint:
*
(no commas, apostrophes, quotes or other symbols)
Warranty Type: Parts
Service Performed: Part(s) Replaced or Credited based on manufacturer requirements
Service Explanation: Part Replaced or Credited based on manufacturer requirements
Parts Claim Details
(no dollar sign or other symbols)
*
Part Number (1)
*
Quantity
*
Price
Reference Number
*
Invoice Number
Part Number (2)
Quantity
Price
Reference Number
Invoice Number
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