Claim Form

• *Email Address

  Claim # (SEMCO use only)

  Date Issue Found (yyyy/mm/dd)

  Product Identification

  Model# or Job#

  Product Category

  -Select- Chilled Beams EP EP-ADM FV Other PVS VP/VS Wheel Duct Panels Sound

  Serial# or Order#

  Failure Category

  -Select- Air Flow Chilled/Hot Water Coil Controls Damper Electrical Performance Built Incorrectly Scope of Work Missing Item(s) Damage Other

  Prod/Equip Owners Information

  Name

  Phone

  Ship to Contact Info

  Name

  Phone

  Product/Equipment Location

  Name

  Address

  City

  STATE (Province)

  -Select- Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland and Labrador North Carolina North Dakota Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Other

  Postal Code

  Country

  -Select- Canada USA Other

  STATE (Province) Name

  Country Name

  Ship to Address

  Name

  Address

  City

  STATE (Province)

  -Select- Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland and Labrador North Carolina North Dakota Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Other

  Postal Code

  Country

  -Select- Canada USA Other

  STATE (Province) Name

  Country Name

  Please provide a detailed description of the failure