File a Claim - Pacmat

RETAILER INFORMATION
Has the Dealer been onsite to view the claim?*
- Yes
- No
Dealer Name*
Dealer Contact Name*
Dealer Phone*
Dealer Email*
Retailer Address*
Street Address Address Line 2 City State ZIP Code
CONSUMER INFORMATION
Consumer Name*
Consumer Phone Number*
Consumer Email*
Consumer address*
Street Address Address Line 2 City State ZIP Code
PRODUCT INFORMATION
Product Name*
Product SKU*
Reference #*
Invoice #*
CLAIM INFORMATION
Date reported*
Date Format: MM slash DD slash YYYY
Submitted By:
Inspection Requested*
- Yes
- No
Describe Issue*
Please upload photos or a short video (30 seconds or less) of your claim here:*
Drop files here or
CAPTCHA

RETAILER INFORMATION