Paladin Heavy (JRB, CP, CWS) Claim Form | Paladin Attachments

Dealer Name *

Contact *

Address *

Phone *

Fax *

Email *

Dealer Claim Number *

Serial # *

PCN # *

Hours *

Machine Model *

Application *

RGA # *

Failure Date *

Month

Day

Year

Repair Date *

Month

Day

Year

Details of Failure *

Corrective Action *

Total Labor Hours *

Total Labor Cost *

Freight *

Misc & Outside Cost *

Part Number

Dealer Part Number

Quantity

Description

Cost

Total Parts Cost *

Total Claim Cost *

Attachments

Files must be less than 64 MB.
Allowed file types: gif jpg jpeg png pdf doc docx ppt pptx gz tar zip.

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