Formulier

Rosemount Claim Form

  1. Customer Information
  2. Product Information

Customer Information

Please avoid using special characters as they will cause the form to error.

Customer Name Vereist
Customer Number
City
State
Country
Submitter Name Vereist
Email Vereist
Phone
Claim Number Non-Collins Claim ID Vereist
Purchase Order/Repair Order Vereist
Contract Applied Contract Name: PSAA, SSC..... Vereist
Letter of Delegation on File
Letter of Delegation on File
Removal: A/C Type Vereist
Removal: A/C Serial #
Removal: A/C Tail # Vereist
Original Fit: A/C Type or Spares PO Vereist
Original Fit: Serial #
Original Fit: Tail # Type N/A if Spares PO Vereist
Manufacturer's Part # One Collins Part Number per claim Vereist
Old/Removed Serial # One Collins Part Number per claim Vereist
New/Installed Serial # One Collins Part Number per claim Vereist
Labor Hours
Labor Rate
Freight
Parts: Part Number Hit ENTER to add more than one part.
Parts: Quantity Hit ENTER to add more than one part.
Parts: Price per Unit Hit ENTER to add more than one part.
Parts: Total Amount Hit ENTER to add more than one part.
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Date of Failure Vereist
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Date of Repair
Complaint Please avoid using special characters as they will cause the form to error.
Corrective Action Please avoid using special characters as they will cause the form to error.
Notes Please avoid using special characters as they will cause the form to error.

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Template Language

Note: Templates are best used when submitting batch claims of registration\retrofits that involved multiple equipment types.