Claim Form ConfirmationA copy of this finished form will be sent to the following emails for your records.Pacmat Rep Email(Required) Claim Submitter's Email(Required) CUSTOMER INFORMATIONPacmat Representative(Required)Date(Required) MM slash DD slash YYYY Retailer Name(Required)Phone(Required)Contact(Required)Street AddressCityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip CodePacmat Invoice NumberPacmat Reference NumberCONSUMER INFORMATIONConsumer NameConsumer PhoneConsumer AddressCityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZIP CodePlease provide copy of consumer invoice and labor bill Drop files here or Select files Max. file size: 20 MB, Max. files: 10. PRODUCT/CLAIM INFORMATIONClaim Submitted By:(Required)Has the dealer been onsite to review claim?Product Name/DescriptionSKUDate Purchased (consumer) MM slash DD slash YYYY SY/SF PurchasedDate Issue Was Noticed By Consumer MM slash DD slash YYYY Date Complaint Was Reported MM slash DD slash YYYY Date Installed MM slash DD slash YYYY Quantity InstalledQuantity Involved in ComplaintRooms InstalledEstimated Labor to ResolveTotal # of Cartons# Cartons Opened# Cartons InstalledAcclimation Yes No Acclimation PeriodMoisture reading of wood prior to install INSTALLATION INFORMATIONInstalled by Retailer Consumer Consumer Contracted Installer Installer NameInstaller PhoneSubfloor Ply-Wood Concrete OSB Other Type of Grade On Grade Below Grade Grade Above Grade Installation Method Glue Float Staple Nail Pad/Underlayment UsedStaple/Nail SizeAdhesive UsedCleaning Method & Products UsedCleaning FrequencyDoes this require and inspection? If yes, please find the inspection agreement by clicking here. Should an inspection be required, the dealer will be responsible for the inspection fee in the case there are no manufacturing related issues.Describe the issueWhat is needed to resolve the issue?Please submit photos and/or other evidence that substantiate the issue with this form(Required)Your file has finished uploading when a red "x" appears next to its name. Then your claim will be ready to submit. Drop files here or Select files Max. file size: 20 MB, Max. files: 10. CAPTCHAEmailThis field is for validation purposes and should be left unchanged. Δ
