Claim Number:

WARRANTY CLAIM FORM .…………

Claim Registration Date:

IDENTIFICATION RETURNING DISTRIBUTOR

F-M Customer Number: Contact: Josip Kvesić
Name of the Returning Distributor: Automerc Škoro
Phone: +387 30 877 201
Address:
Email: Josip.kvesic@automerskoro.com
Street & Number: Sarajevska cesta 71

Postal Code &Location: 71250 Kiseljak

Country: Bosnia and Hercegovina

IDENTIFICATION RETURNING SELLER or INSTALLER

Name of the Returning Installer: Auto-Vojniković t.r. Contact: Asim Vojniković
Street & Number: Safeta Zeljke 53
Postal Code &Location: 71000 Sarajevo Phone: +387 61 172 775
Country: Bosnia and Hercegovina
Email: auto.vojnikovic@gmail.com
VEHICLE INFORMATION
Vehicle Brand: VW Model: Caddy Year of Manufacturing: 2006
INFORMATION FOR ENGINE PRODUCTS INFORMATION FOR BRAKING CV PRODUCTS
Engine Manufacturer: VW Friction Product Axle Position :
Engine Model/Capacity (kW): 2,0 SDI Front: Y/N ? Centre: Y/N ? Rear: Y/N ?
Serial Number / Typ Mine (France): Friction Material Grade of Failing Product:
Engine Manufacturing Year: 2006 Friction Material Grade on other Axles:
INFORMATION ABOUT THE FAILING PRODUCT
Part Number:   CAM968 Description (name): Quantity:  1
Date of Installation: 18.01.2019. Mileage (km): 254 239 Date of Failure: 10.05.2019. Mileage (km): 263 119

DESCRIPTION OF THE FAILURE

Camshaft break in 2 peaces.

REASONS FOR ORIGINAL OVERHAUL/REPLACEMENT AND DETAILS OF ALL WORK CARRIED OUT AT THE TIME

CUSTOMER CLAIM
Parts Claim: Labour Claim: Other Costs (describe): -
Free of Charge Replacement (Yes/No): Time Spent (minutes):
Labour Cost(Euro):
Other Costs (Value): -
Reimbursement*(Yes/No):
(*) Only after parts have returned to F-M

Customer Signature:……………………….….. Print Name: Claim No. Date:

WARRANTY CLAIM REVIEW by FEDERAL-MOGUL WARRANTY MANAGER

Name Reviewer: Date of Review: Claim Review: Failure Code:
Day / M / Yr Accepted Rejected
Reason for Rejection:

TO RECLAIM ANY COSTS, PLEASE ADD TO THIS WARRANTY CLAIM FORM A COPY OF ALL INVOICES SUPPORTING THE COSTS INCURRED.
PLEASE ATTACH A COPY OF THIS DOCUMENT TO THE GOODS YOU ARE RETURNING
IMPORTANT: Warranty will be rejected if the components have been dismantled or modified. Federal-Mogul reserves the right to destroy, without financial
compensation, the components in order to effect the examination requested. E.g. destructive testing in an independent or Federal-Mogul laboratory.
FEDERAL-MOGUL GLOBAL AFTERMARKET – WARRANTY DEPARTMENT
Prins Boudewijnlaan 7, B-2550 Kontich, Belgium