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Electronic Claim Form

For the convenience of our patrons, we are providing this electronic claim form for instant submission of warranty claims. If you would prefer to download a faxable copy of the claims form, click here.

* Denotes required fields.
* Dealer Name:    
* Attn:    
* Address:    
* City:    
* State:    
* Zip:    
* Phone:    
* Fax:    
* Email:    
* PLCG Serial #:    
* HRS (on attachment):    
* RMA#:    
* PLCG Attachment Desc:    
* Repair Date:    
* Machine Model:    
* Failure Date:    
* Application:    
* Details of Failure:    
* Corrective Action:    
* Total Labor Hours:    
* Total Labor Costs:    
* Freight:    
* Dealer Invoice No:    
* Misc Costs - i.e. outside Costs
(Submit Service Invoice along with Supporting Documentation):
     
Qty: Part #: Description: Cost:
           
    Total Parts Cost:
    Total Claim Cost:
     
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