Installed Claim Form

AD Rep Email

Claim Submitter's Email

AD Representative

Date

Retailer Name

Phone

Contact

Street Address

City

State

Zip Code

AD Invoice Number

AD Reference Number

Consumer Name

Consumer Phone

Consumer Address

City

State

ZIP Code

Please provide a copy of the consumer invoice and labor bill.

Claim Submitted By:

Has the dealer been onsite to review claim?

Product Name/Description

SKU

Date Purchased (Consumer)

SY/SF Purchased

Date Issue Was Noticed By Consumer

Date Complaint Was Reported

Date Installed

Quantity Installed

Quantity Involved in Complaint

Rooms Installed

Estimated Labor to Resolve

Total # of Cartons

# Cartons Opened

# Cartons Installed

Acclimation

Acclimation Period

Moisture reading of wood prior to install

Installed By

Installer Name

Installer Phone

Subfloor

Type of Grade

Installation Method

Pad/Underlayment Used

Staple/Nail Size

Adhesive Used

Cleaning Method & Products Used

Cleaning Frequency

Describe the issue

What is needed to resolve the issue?

Please submit photos and/or other evidence that substantiate the issue with this form

Does this require an inspection? If yes, please find the inspection agreement hereopens PDF file . Should an inspection be required, the dealer will be responsible for the inspection fee in the case that there are no manufacturing related issues.