Refrigerant Leak Claim Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.1234Technician First Name *Technician Last Name *Technician Email *Technician Phone *Callback Number (if different)Dealer / Company Name *CE Account Number *6-digit CE customer account number. Original HTML also includes an account-hold warning for flagged accounts.Service Manager's EmailService Manager's PhoneWarehouse / Branch # being shipped to4-digit warehouse or branch code.RegionEastWestCentralWorking with a specific TSR/CAM?NONEBen EvansMichael SquiresNextSave and Resume LaterEnd User First Name *End User Last Name *Street Address *City *Province *Postal Code *No spaces: A1B2C3 format.Homeowner PhoneHomeowner EmailOriginal Equipment Owner?YesNoPreviousNextSave and Resume LaterEquipment Type *DuctlessResidentialCommercialEquipment Model Number *Equipment Serial Number *BrandCarrierBryantPayneOtherInstallation / Startup Date *Fail DateFactory Ship Date (Trend / ICIES)Equipment Information / HistoryProvide any pertinent history including repairs, failures, or issues.PreviousNextSave and Resume LaterWas a leak test performed? *YesNoWas the leak identified? *YesNoThe source form warns that warranty approval requires proof of the actual leak location.Is the leak repairable? *YesNoIs this a DOA leak (within 30 days of startup)?YesNoLeak Type *Solder JointPunctureTube failure/crackLeak Location *U-bendIn fin packAt tube sheetDistributor / headerFactory pipingCoaxial heat exchangerCompressor ShellBPHXLeak's Possible CauseOperating vibrationOperating rub (metal, tubes, wires, etc)Manufacturing workmanshipEnvironmental corrosionShippingRefrigerant TypeR-410AR-22R-32R-454BOtherAmount of Refrigerant Lost (lbs/oz)Detection MethodBubble testElectronic detectorUV dyeOtherDescription of the Leak and its LocationLeak Proof: Videos / Photos * Drag & Drop Files, Choose Files to Upload You can upload up to 4 files. Must show bubbles or the detector tip at the leak location. Oil stain photos alone are not accepted.What is being requested?Labor/material assistance for repairing a repairable leakApprove a Replacement UnitPreviousSubmitSave and Resume Later
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