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Web Form
Claims Facilitation Form
Customer First Name:
Customer Last Name:
Customer Phone (Digits Only):
Phone Type
Mobile
Work
Home
Sales Order Number:
Customer Email:
Communication Preference:
Phone
Email
Address:
Is this a business?
Yes
No
City:
State:
Select
AL
AK
AA
AZ
AR
AE
AP
AS
CA
CO
CT
DE
DC
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MR
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
VI
UT
VT
VA
WA
WV
WI
WY
Zip:
Product Description:
Model:
Manufacturer:
Purchase Date:
Serial:
Retailer:
Unit Failure Description :
Accidental Damage Claim:
No
Yes
Who was using the item?
Where did the incident occur?
When did the accident occur?
How did the accident occur?
What is damaged?
Furniture Claim:
No
Yes
Date Failure was Identified:
Attach Invoice and/or Images:
Person Submitting Request:
Person Submitting Request Phone:
Phone Type
Mobile
Work
Home
Person Submitting Request Email:
Has anyone in the home been diagnosed or tested due to symptoms for COVID-19 in the last 14 days?
Choose..
No
Yes
Has anyone in the home has any combination of symptoms consistent with COVID-19 in the last 7 days?
Choose..
No
Yes
Has anyone in the home come in close contact (within 6 feet) with someone who has been diagnosed with or waiting test results for COVID-19 due to symptoms within 14 days?
Choose..
No
Yes
Date of Request:
2024-Dec-04
Be as specific as possible
Customer covers cost of repairs
Explain what is not functioning properly. Be as specific as possible.
Please attach images if this is a furniture claim.
Please attach images if this is an Accidental Damage from Handling claim.