Warranty Claim Form

Distributor Company Name*

User Company Name

Address of User

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Part Number & QTY. (Example: 36161-55 QTY. 2)*

Serial # of Equipment*

Part Description

Part Failure Description*

Comments & Address where Replacement Equipment to be sent to if you selected to have Replacement Part.*

File Upload (Photos, Invoices, Info outside of the Warranty Form in correspondence to the Claim)

If claim is approved Distributor opts to receive:*

Replacement PartCredit to Account

Reminder: Distributor to keep any defective part for 45 days or until otherwise instructed by Raasm. Note: I certify that the above information is correct. I understand that incomplete and/or unsigned claims will not be processed.

Email

example@example.com

Submitted By*

First NameLast Name

Signature

RAASM USA ACCEPTS THE CLAIM YN

Raasm Internal Use

SUBJECT TO RECEIPT OF ADDITIONAL INFORMATION YN

Raasm Internal Use