Distributor
Name:
Contact Email:
Address:
City:
Province:
Postal Code:
Internal Claim #:
Details
User:
Address:
Loader-Model / Grapple-Model:
Hours in Service (Machine) / Loader or Grapple
Date of Claim:
Serial No:
Hours in Service (Defective Part):
Date Parts Returned:
Date Delivered:
Date of Failure:
Date Parts Replaced:
Parts Replaced
Qty
Damaged Part Number
Description
Replaced on Rotobec Invoice
List Each
Cost or Discount
Amount Claimed
$
$
$
Reasons For Claim:
Must be less than 1000 characters. Current count:
By:
Hours
Rate
Amount Claimed
Shop Labor
$
$
Field Work
$
$
Travel Time
$
$
Supplemental Pictures
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