Customer Service Claim Form

1. CLAIM INFORMATION

Please select the type of claim you are submitting: *

Equipment Claim
Part Claim
Miscellaneous Claim (invoices, part shortages, shipping discrepancies, etc.)

Please describe the detailed nature of the claim. This information is required to process your claim. *

Provide as much information as possible. You will also have the opportunity to attach images, videos, or files in section 3.

2. PRODUCT INFORMATION

Please provide the following information, so we can reach you with questions, claim status updates, and resolutions. (If any information is unavailable, please type "unknown" in the field.)

Customer purchase order OR sales order number: *

The customer purchase order used to purchase the item(s) in question.

Product serial number: *

Serial number on the item(s) in question.

Corken model number or part number: *

The model number or part number for the item(s) in question.

Distributor's Name: *

The Corken Distributor handling the claim.

EQUIPMENT CLAIM SECTION

This section is for equipment claims only. Please skip to Section 3 if your claim is for a Part or Miscellaneous claim.

Approximate date the equipment was placed into service:

Approximate date the equipment was taken out of service:

Approximate hours of service or gallons pumped (if applicable) for the equipment.

Product type handled with the equipment in question. (i.e. LPG, Diesel, etc.)

3. FILE UPLOAD

Upload up to five images, documentation, or other information that provides further detail about the claim.

Files:

Click or drag files to this area to upload. You can upload up to 5 files.

Additional Comments:

4. PRIMARY CONTACT INFORMATION

Name: *

First

Last

Company Name:

Return Ship To Address *

Street Address

City, State (Country), Postal Code (Zip) *

Phone *

Email *

Please use the email address associated with your original purchase

Please contact me by phone or email with next steps *

I agree to receive call(s) or email(s) related to this topic.

Claim Submitter Name (if different from primary contact above)