Service Claims Entry
Fields Marked with an Asterisk are Required Entry Fields
Repair Order
-
-
Customer Information
Product Information
Customer Name:
Customer Address (1):
Customer Address (2):
City, State Zip:
Telephone Number:
Class:
Manufacturer:
Model:
Serial Number:
Product Purchase Date:
Invoice:
Product Purchase Price:
Verify Customer/Product Information
Verified
Invoice Number
*
Invoice Date (mm/dd/yyyy)
*
Service Dates (mm/dd/yyyy)
From
*
To
*
Service Site
Carry In
In Home
Description of Repair
Loss Codes
Loss Code Descriptions
%%Replace Defective Part%%
*
Loss Code Descriptions
%%Replace Defective Part%%
Loss Code Descriptions
%%Replace Defective Part%%
Failed Parts
Part Number
Part Description
Amount
(1)
(2)
(3)
(4)
(5)
Summary of Charges:
Parts
Labor
Trip
Tax
Other
Description of Other Charge
%%Shipping%%
Other
Description of Other Charge
%%Shipping%%
Other
Description of Other Charge
%%Shipping%%
Total Charges
*
