Claim Form SubmissionA copy of this finished form will be sent to the following emails for your records.PacMat Rep Email* Claim Submitter's Email* CUSTOMER INFORMATIONPacMat Representative* Date* MM slash DD slash YYYY Retailer Name* Phone*Contact* Street Address* City* State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code* T&A Invoice Number* T&A Reference Number* CONSUMER INFORMATIONConsumer Name* Consumer Phone*Consumer Address* City* State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZIP Code* Please provide copy of consumer invoice and labor bill Drop files here or Select files Max. file size: 20 MB, Max. files: 2. PRODUCT/CLAIM INFORMATIONHas the dealer been onsite to review claim?* Product Name/Description* SKU* Date Purchased (consumer)* MM slash DD slash YYYY SY/SF Purchased* Date Issue Was Noticed By Consumer* MM slash DD slash YYYY Date Complaint Was Reported* MM slash DD slash YYYY Date Installed* MM slash DD slash YYYY Quantity Installed* Quantity Involved in Complaint* Rooms Installed Estimated Labor to Resolve Total # of Cartons # Cartons Opened # Cartons Installed Acclimation* Yes No Acclimation Period Moisture reading of wood prior to install INSTALLATION INFORMATIONInstalled by* Retailer Consumer Consumer Contracted Installer Installer Name* Installer Phone*Installer License & Bond Info Subfloor Ply-Wood Concrete OSB Other Type of Grade* On Grade Below Grade Grade Above Grade Installation Method Glue Float Staple Nail Pad/Underlayment Used Staple/Nail Size Adhesive Used Cleaning Method & Products Used Cleaning Frequency Does this require and inspection? If yes, please find the inspection agreement by clicking here. Should an inspection be required, the dealer will be responsible for the inspection fee in the case there are no manufacturing related issues.Describe the issue*What is needed to resolve the issue?*Please submit photos and/or other evidence that substantiate the issue with this form* Drop files here or Select files Max. file size: 20 MB, Max. files: 2. CAPTCHANameThis field is for validation purposes and should be left unchanged. Δ *Please allow 24-48 hours for a response. Thank you for your patience.
