JX | Warranty Claim Form

JX Warranty Claim Form-2017-R2

Customer Information
Sponsoring Branch*
Fleet Name*
Acct Number*
Fleet Contact Name*
Phone*
Email*
Vehicle Information
Work Order/RO#*
Date of Failure*
MM slash DD slash YYYY
Make*
Mileage @ Time of Failure*
Vehicle Serial Number*
Complaint
Cause
Investigation
Correction
Claim Information
Total Repair Hours Claimed
Labor Rate per/hr
Parts
Number Description Qty Price Ea. Total
Sublet Invoice Info
List
$ Amt (USD) Description
Total Labor
Total Parts
Total Sublet
Claim Total
Attach Supporting Files
Drop files here or

Accepted file types: pdf, docx, jpg, png, doc, gif, Max. file size: 200 MB.
Signature*
Email*

Number	Description	Qty	Price Ea.	Total

$ Amt (USD)	Description

Customer Information