WARRANTY REQUEST FOR CREDIT

For more information, please call Heil of Texas at 713-923-7600.

This warranty request is designed to be completed by the applicant and submitted with all the (*) required fields as marked below.
PLEASE FILL THE OWNER INFORMATION OUT BELOW

Distributor Information

Owner Information
Distributor #1997203
Heil of Texas
5900 Wheeler
Houston, TX 77023
Owner:*
Attn:*
Address:*
City, State, Zip:*
Email Address:*

Serial Number:

 In Service: Failure Date: Repair Date:

CHASSIS INFORMATION

Vin Number:

 Make: Model: Engine Hours:

What was the customers complaint? Please be specific.
What did you do to repair the machine? Be specific, (REPAIR AND REPLACE) is not acceptable.
Heil of Texas Invoice Number(s) for parts used in repair: If more than one separate with a comma.
      ($) Credit Requested  
Quantity Heil Part Number Description/Replacement Part Serial Number Each

Total
# $

$
# $

$
# $

$
# $

$
# $

$
# $

$
# $

$

Total Heil Purchased Parts:

$

Total Labor:

$

Total Outside Matl/Parts:

$

Total Freight:

$

CALCULATE CLAIM TOTAL BEFORE HITTING SUBMIT BELOW:

$

ADDITIONAL INFORMATION
SUBMIT WITHIN 14 DAYS FROM DATE REPAIRS COMPLETED. VOID IF NOT RECIEVED WITHIN 60 DAYS
SIGNATURE* DATE*

Please sign and date this form and hit the submit button below.