Dealer must inspect prior to submitting claim form. Please fill out the form in its entirety. RETAILER INFORMATIONPacMat Sales Representative*Retailer Name*Contact Name*Retailer Phone Number*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 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*PacMat Invoice Number*PacMat Reference Number*PURCHASE HISTORYDate purchased by Consumer* Date Format: MM slash DD slash YYYY Date issue noticed by Consumer* Date Format: MM slash DD slash YYYY Date complaint reported* Date Format: MM slash DD slash YYYY Date installed* Date Format: MM slash DD slash YYYY Quantity installed*Quantity involved in complaint*Rooms installed*Quantity purchased*Please indicate s/yds or s/fCAPTCHA
