Receipt Email

Date of Claim

* For internal use only

Claim Number (DE)

Date of Equipment Failure *

Dealer Reference # *

Customer

Company Name *

Last Name *

First Name *

Address *

City / Town *

Country Select * Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua And Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia And Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (keeling) Islands Colombia Comoros Congo Congo, The Democratic Republic Of The Cook Islands Costa Rica Cote D'ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-bissau Guyana Haiti Heard Island And Mcdonald Islands Holy See (vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic Of Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic Of Korea, Republic Of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macao Macedonia, The Former Yugoslav Republic Of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States Of Moldova, Republic Of Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Helena Saint Kitts And Nevis Saint Lucia Saint Pierre And Miquelon Saint Vincent And The Grenadines Samoa San Marino Sao Tome And Principe Saudi Arabia Senegal Serbia And Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia And The South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard And Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province Of China Tajikistan Tanzania, United Republic Of Thailand Timor-leste Togo Tokelau Tonga Trinidad And Tobago Tunisia Turkey Turkmenistan Turks And Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands, British Virgin Islands, U.s. Wallis And Futuna Western Sahara Yemen Zambia Zimbabwe

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P.C. *

Product

Product Select * -- Products -- ProTill Strawmaster Land Rollers Rock Removal Manure Spreaders Rotary Cutter Bulldozer Blades

Model Select * -- Models -- PRO-TILL - 33FT PRO-TILL - 40FT PRO-TILL - 30FT PRO-TILL - 36FT PRO-TILL - 41FT PRO-TILL - 45FT PRO-TILL - 20FT PRO-TILL - 26FT PRO-TILL - 28FT PRO-TILL - 20FT HD PRO-TILL - 26FT HD PRO-TILL - 14FT NT PRO-TILL - 17FT NT PRO-TILL - 20FT NT SCORPION HITCH - 3PLEX SCORPION HITCH - BIFOLD STRAWMASTER 5 ROW STRAWMASTER 5 ROW - 30FT STRAWMASTER 5 ROW - 50FT STRAWMASTER 5 ROW - 70FT STRAWMASTER 5 ROW - 82FT STRAWMASTER 7 ROW - 50FT STRAWMASTER 7 ROW - 70FT STRAWMASTER 7 ROW - 82FT STRAWMASTER 5 ROW - 54FT NT STRAWMASTER 5 ROW - 38FT NT STRAWMASTER - EURO - 22FT STRAWMASTER - EURO - 30FT STRAWMASTER PRO 80FT STRAWMASTER PRO 100FT STRAWMASTER PRO 120FT STRAWMASTER+ STRAWMASTER+ 5 ROW - 70FT STRAWMASTER+ 5 ROW - 90FT STRAWMASTER+ 7 ROW - 70FT STRAWMASTER+ 7 ROW - 90FT LANDROLLER 20FT LANDROLLER 34FT LANDROLLER 45FT LANDROLLER 51FT LANDROLLER 64FT LANDROLLER 80FT LANDROLLER - LRX 36 LANDROLLER - LRX 41 LANDROLLER - LRX 46 LANDROLLER - LRX 51 LANDROLLER - LRX 57 LANDROLLER - LRX 51 ROCK PICKER - 6000 ROCK PICKER - 7200 ROCK KING 9600 R570P - PRONG TYPE RR1500 ROCK RAKE RD320 ROCK DIGGER MANURE SPREADER - M28 MANURE SPREADER - M34 ROTARY CUTTER - 10FT ROTARY CUTTER - 15FT SIDEARM 1220 SIDEARM 1800 SIDEARM 1820 LIQUIFIRE 7900 SERIES 7200 SERIES 6900 SERIES 6600 SERIES 5900 SERIES 46/5700 SERIES 3500 SERIES 34/44 SERIES SPEED BLADE SILAGE KING STRONGBOX

Tractor When Applic. *

Size or Hours *

Drive Type *

Serial # *

Sale Date *

Order

* For internal use only

W#

Account #

Sales Order #

Credit Memo #

Receiving #

Dealer

Name *

City / Town *

PH. # *

Country Select * Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua And Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia And Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (keeling) Islands Colombia Comoros Congo Congo, The Democratic Republic Of The Cook Islands Costa Rica Cote D'ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-bissau Guyana Haiti Heard Island And Mcdonald Islands Holy See (vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic Of Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic Of Korea, Republic Of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macao Macedonia, The Former Yugoslav Republic Of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States Of Moldova, Republic Of Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Helena Saint Kitts And Nevis Saint Lucia Saint Pierre And Miquelon Saint Vincent And The Grenadines Samoa San Marino Sao Tome And Principe Saudi Arabia Senegal Serbia And Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia And The South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard And Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province Of China Tajikistan Tanzania, United Republic Of Thailand Timor-leste Togo Tokelau Tonga Trinidad And Tobago Tunisia Turkey Turkmenistan Turks And Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands, British Virgin Islands, U.s. Wallis And Futuna Western Sahara Yemen Zambia Zimbabwe

Province Select * -- Provinces -- Ontario Quebec Nova Scotia New Brunswick Manitoba British Columbia Prince Edward Island Saskatchewan Alberta Newfoundland and Labrador Northwest Territories Yukon Nunavut

State Select * -- States -- Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Federated States Of Micronesia Florida Georgia Guam Gu Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

PC. /zip code *

Distributor (if applicable)

Name

City / Town

Country Select Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua And Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia And Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (keeling) Islands Colombia Comoros Congo Congo, The Democratic Republic Of The Cook Islands Costa Rica Cote D'ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-bissau Guyana Haiti Heard Island And Mcdonald Islands Holy See (vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic Of Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic Of Korea, Republic Of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macao Macedonia, The Former Yugoslav Republic Of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States Of Moldova, Republic Of Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Helena Saint Kitts And Nevis Saint Lucia Saint Pierre And Miquelon Saint Vincent And The Grenadines Samoa San Marino Sao Tome And Principe Saudi Arabia Senegal Serbia And Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia And The South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard And Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province Of China Tajikistan Tanzania, United Republic Of Thailand Timor-leste Togo Tokelau Tonga Trinidad And Tobago Tunisia Turkey Turkmenistan Turks And Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands, British Virgin Islands, U.s. Wallis And Futuna Western Sahara Yemen Zambia Zimbabwe

Province Select -- Provinces -- Ontario Quebec Nova Scotia New Brunswick Manitoba British Columbia Prince Edward Island Saskatchewan Alberta Newfoundland and Labrador Northwest Territories Yukon Nunavut

State Select -- States -- Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Federated States Of Micronesia Florida Georgia Guam Gu Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Phone #

Reason and Corrective Action Taken (PLEASE ATTACH AT LEAST ONE PICTURE)

Description of Failure *

Picture or file *

No bigger than 5MB

Picture or file

No bigger than 5MB

Picture or file

No bigger than 5MB

Picture or file

No bigger than 5MB

Check all That Apply

Warranty
Yes

Shortage
Yes

Parts have been retained & tagged
Yes

Parts have been returned To factory
Yes

Manufacturer's Use Only

* For internal use only

Class

Arrival Date

Description

Parts To Be Picked Up?
Yes

#	Quantity	Part #	Item Description	Invoice #	Amount	Total	Manufacturer's use Only
1
2
3
4
5
6
7
8
9
10
11

Total Claim Request

Parts

Labor

Hours

Labor Rate

Freight

Total Claim

Manufacturer's Use Only

* For internal use only

Parts
Labor
Freight
Sub-Total
Taxes
Credit

Customer Service Manager

Date