WARRANTY PRE-APPROVAL FORM (MEDIUM- & HEAVY-DUTY)
(Red items are required.)

All required fields must be filled out for pre-approval.

If you have any questions, please call +1 (800) 401-9866, Option 2.

Dealer Code:

Company:

Date:

03/12/10

First Name:

Middle Name:

Last Name:

Address Line 1:

Address Line 2:

City:

State:

Zip/Postal Code:

Country:

Phone 1:

Phone 2:

Fax:

E-mail:

Web Address:

Labor Rate Per Hour:

Make:

Ford Freightliner GM International Kenworth Mack Peterbilt Sterling Volvo Western Star Other

Model:

Year:

20012002200320042005200620072008200920102011

Mileage:

  Miles Km

17-Digit VIN No.:

Build Date:

In-Service Date:

Application:

Owner:

Make:

Caterpillar Cummins Detroit Diesel International Mack

Model:

Torque:

  lbs-ft N-m

Horsepower:

  hp kw

Axle Type:

Single Tandem Tri-Axle

Suspension:

Air Spring

PTO's:

 None    6-Bolt    2 6-Bolt    8-Bolt

Model No.:

* Serial No.:

(Example: M040301001)

* B/M No.:

(Example: 301706-1)

*Note: Warranty claim cannot be registered without B/M & Serial Nos.

Lube:

Standard Synthetic

Fail Date:

Work Order No.:

Complaint: