Dealer Information:

GNE Account Number: i.e. JON001

Company Name: enter your company name if applicable

Primary Claim Contact: person entering information

Address: enter your address

City: enter your city

State: enter your state

Zip: enter your zip code

Telephone: enter your phone number

Email: enter your email address

Customer Reference Number: enter your job reference number

Customer Information:

Company Name: enter your customer's information (if applicable)

Primary Contact: enter your customer's first and last name

Address: enter your customer's address

City: enter your customer's city

State: enter your customer's state

Zip: enter your customer's zip code

Telephone: enter your customer's phone number

Email: enter your customer's email address

Equipment Information:

Dosko Model Number: enter the units model number(i.e. BHVH2213GX)

Dosko Serial Number: enter the units serial number(i.e. BHVH2213GXAXXXXXXXX)

Warranty Details:

Original Purchase Date: enter date of sale on sales receipt

Failure Date: enter date the unit failed

Repair Date: enter the date you repaired the unit

Hours of Use: enter hours machine has been used

Description of Problem & Detail of Repair: Please give a complete description of problem, part in which caused the problem and detail(s) of repair

Subtotals and Additional Charges:

Other Charges: please give details on other charges if applicable

Posted Shop Labor Rate: enter your hourly posted shop labor rate

Hours Worked: enter hours worked on repair