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* Dealer InformationHas the Dealer been onsite to review the claim?* Yes No Dealer Name* Dealer Contact Name* Dealer Contact Phone*Dealer Contact Email* Dealer Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code CONSUMER INFORMATIONConsumer/Job Site Information* Consumer/Job Site Name* Consumer/Job Site Phone*Consumer/Job Site Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PRODUCT INFORMATIONProduct Name* Product SKU* Reference #* Invoice #* Inspection Required* Yes No CLAIM INFORMATIONDate reported* MM slash DD slash YYYY Submitted By:* Describe the issue*Please attach any evidence to support your claim here (documents, pics, 30-second videos, etc.)Your file has finished uploading when a red "x" appears next to its name. Then your claim will be ready to submit. Drop files here or Select files Max. file size: 50 MB, Max. files: 5. CAPTCHACommentsThis field is for validation purposes and should be left unchanged. *Please allow 24-48 hours for a response. Thank you for your patience.
