TMWD CLAIM No.

:
Warranty Claim Form
TMWD:
All information must be provided before claim can be
procesed by the TecBrake Service Center (TSC).

Engine Brakes
FLEET DISTRIBUTOR

DISTRIBUTOR: CONTACT NAME:

LOCATION: PHONE NO.:

REPAIR FACILITY: CONTACT NAME:

LOCATION: PHONE NO.:
CUSTOMER: CONTACT NAME:
LOCATION: PHONE NO.:

MO/DAY/YR
DATE CLAIM SUBMITTED: ENGINE MODEL: ENGINE BRAKE S/N:
DATE IN SERVICE: ENGINE SERIAL No.: ENGINE BRAKE MOD.:
DATE OF FAILURE: ENGINE CPL(IF APPLY) TRUCK MAKE:
MILER/HRS. IN SERVICE: TURBO MODEL: MODEL & YEAR:

QTY PART NUMBER PART DESCRIPTION UNIT COST EXTENDED

INCLUDE THE FOLLOWING DOCUMENTARION WITH CLAIM: TOTAL PARTS $

1) OEM PARTS INVOICE OR LIST HOURLY LABOR RATE
2) WORK ORDER OR REPAIR ORDER HOURS REQUIRED
3) RELEVANT SUPPORTING DOCUMENTATION TOTAL LABOR $
TOTAL CLAIMED $

REQUIRED COMMENTS: (1) OPERATOR COMPLAINT (2) CAUSE (3) CORRECTION

TSC ANALYSIS AND COMMENTS WARRANTY DISPOSITION & REIMBURSEMENT

APPROVED DENIED MODIFIED
PARTS ALLOWED: LABOR ALLOWED:
TOTAL ALLOWED ON CLAIM: DATE:
MO/DAY/YR
CREDIT MEMO No.:
CHECK No.:
PARTS SHIPPED ON S.O. No.:

Tec Brake Inc. P.O. Box 27822 Houston, Texas 77227 1997 Tec Brake Bulletin No. TB990129 05/20/97