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?*YesNoDealer 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*YesNoCLAIM INFORMATIONDate reported* Date Format: 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 CAPTCHANameThis field is for validation purposes and should be left unchanged.*Please allow 24-48 hours for a response. Thank you for your patience.