Dealer must inspect prior to submitting claim form. Please fill out the form in its entirety. Claim Form SubmissionA copy of this finished form will be sent to the following emails for your records.Pacmat Rep Email* Claim Submitter's Email* RETAILER INFORMATIONHas the Dealer been onsite to view the claim?*YesNoDealer Name*Dealer Contact Name*Dealer Phone*Dealer Email* Retailer Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code CONSUMER INFORMATIONConsumer Name*Consumer Phone Number*Consumer Email* Consumer address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PRODUCT INFORMATIONProduct Name*Product SKU*Reference #*Invoice #*CLAIM INFORMATIONDate reported* Date Format: MM slash DD slash YYYY Submitted By:Inspection Requested*YesNoDoes this require an inspection? If yes, please read our 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 Issue*Please upload photos or a short video (30 seconds or less) of your claim here:* Drop files here or CAPTCHA