1130 Stuart Drive, Merced, CA 95341
P: (209) 722-4145 F: (209) 349-8934

Warranty Consideration Questionnaire Form

Claim#: RGA#:


Customer Name*: Dealer*:

Machine Serial No*: Machine Sale Date*:

Gearbox/Motor Serial No:*: Part No*:

Date Gearbox/Motor Put In Use*: Hours In Use*: Failure Date*:

Provide Invoice No. purchased or specify if unit was original equipment:

Description of Complaint:

Gearbox/Motor disassembled? If so, provide report:

Regular maintenance/inspections preformed:

Oil leaking:

Oil black/Current oil level:

Noise? Grinding, squeal, clack:


Load empty/load full:

Shifting problems:

Shafts spin freely/seized:

Additional Comments:

Signed by Dealer: Print: Date Signed:

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