Service Call Reimbursement

Request reimbursement for service calls. Our team is here to help you complete your request and answer questions.

Service Call Reimbursement Form

Form Reference #:

Date:

Service Company Information

Company Name:*

Phone:*

Company Address:*

Fax:

Customer Information

Customer Name:*

Phone:*

Email:

Company Website (leave blank):

Service Address:*

City:*

State:*

ZIP:*

Service Details

Service Date:*

Service Time:*

Original Installation Date:*

Part Details

Part Number Being Replaced:*

Serial Number (if available):

Replacement Part Number:*

New Serial Number:

Warranty Status:*

Work Description

Explain what was done and why:*

Reimbursement Details

Reimbursement is provided for replacing a defective water heater flex and the work involved for returning to the installation sight to re-service the customer's failed flex and replace with non-defected item. This is to be paid individually per each return service made to replace defective item.

Reimbursement Amount:

$150.00

Normal Service Call Rate:

Additional Expenses (if any):

Distance Traveled (miles):

Signatures

Service Person

Signature:

Print Name:*

Date:*

Manufacturer Representative

Signature:

Print Name:*

Date:*

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