TMWD CLAIM No.

Warranty Claim Form

TMWD:
All information must be provided before claim can be
procesed by the TecBrake Service Center (TSC).
Engine Brakes

FLEET

DISTRIBUTOR

DISTRIBUTOR:
LOCATION:

CONTACT NAME:
PHONE NO.:

REPAIR FACILITY:
LOCATION:

CONTACT NAME:
PHONE NO.:

CUSTOMER:
LOCATION:

CONTACT NAME:
PHONE NO.:

DATE CLAIM SUBMITTED:

MO/DAY/YR

ENGINE MODEL:

ENGINE BRAKE S/N:

DATE IN SERVICE:

ENGINE SERIAL No.:

ENGINE BRAKE MOD.:

DATE OF FAILURE:

ENGINE CPL(IF APPLY)

TRUCK MAKE:

MILER/HRS. IN SERVICE:

TURBO MODEL:

MODEL & YEAR:

QTY

PART NUMBER

PART DESCRIPTION

INCLUDE THE FOLLOWING DOCUMENTARION WITH CLAIM:

1) OEM PARTS INVOICE OR LIST
2) WORK ORDER OR REPAIR ORDER
3) RELEVANT SUPPORTING DOCUMENTATION

UNIT COST

TOTAL PARTS
HOURLY LABOR RATE
HOURS REQUIRED
TOTAL LABOR
TOTAL CLAIMED

REQUIRED COMMENTS: (1) OPERATOR COMPLAINT

(2) CAUSE

EXTENDED

$
$

(3) CORRECTION

WARRANTY DISPOSITION & REIMBURSEMENT

TSC ANALYSIS AND COMMENTS

DENIED

APPROVED
PARTS ALLOWED:

TOTAL ALLOWED ON CLAIM:

MODIFIED
LABOR ALLOWED:
DATE:
MO/DAY/YR

CREDIT MEMO No.:

CHECK No.:
PARTS SHIPPED ON S.O. No.:
Tec Brake Inc.

P.O. Box 27822

Houston, Texas 77227

1997 Tec Brake

Bulletin No. TB990129

05/20/97