CP Parts S/O # / RGA #
ECB/Service Tip / Distributor Acct. #
Distributor Name: / Compressor Owner Name:
Address: / Address:
City: / State: / Zip: / City: / State: / Zip:
Distributor Claim ID: / Date of Claim: / Work Performed By: / Claim Prepared By:
L1/L2 / L1/L3 / L2/L3 / L1 / L2 / L3
Model: / Unit S/N: / Volt Readings: / Amp Readings:
Ship Date: / Start Date: / Failure Date: / Repair Date: / Total Hours: / Load Hours:
All Motors Require Fault Notification Forms: / Attached / Submitted
Compressor Site Conditions (i.e. Indoors/out, dusty/clean, heated, type of operation):
Reported Problem:
Cause:
Corrective Action:
ENTER PRIMARY PARTS HERE – USE SUPPLEMENTAL PAGE IF NECESSARY
PARTS REPLACED / Description / Article Number / Qty. / List Price/Ea. / Disc. / Total Net
Supplemental Parts Sub-Total
Parts Total (All Above and Supplemental Parts)
Labor* / Travel / On Site / Total Hrs. / Rate
Mileage / Miles / No. of Trips / Rate $ 0.65
Miscellaneous Expenses (Attach explanation and invoices)
Total Amount Requested On This Claim
ALL CLAIMS MUST BE SUBMITTED WITHIN 30 DAYS
To: or Fax: (803) 817-7468
*Labor will be paid at 70% of Distributor published shop rate
/ Authorized By: / CP Claim #CP Parts S/O # / RGA #
ECB/Service Tip / Distributor Acct. #
Note: Claims will not be processed if items Highlighted are not on Warranty Claim Application
Field Name / DescriptionAuthorized By / Chicago Pneumatic Multibrand Compressor Technical Service Representative Authorizing work to be completed.
CP Claim # / Given by CP Technical Service Representative
CP Parts S/O # / Sales Order for parts to complete repair
Distributor Acct. # / Distributor Account number used to order parts or to receive credit for claim
Distributor / All Distributor information (Name, Address)
Customer / All Compressor/Dryer owner information (Name, Address)
Distributor Claim ID: / For reference if required by Distributor
Date of Claim / Date Claim Submitted
Work Performed By / Name of technician completing the repair
Claim Prepared By / Name of person submitting the claim for contact
Model / Complete Compressor/Dryer Model (QRS 7.5HPD, CPC 40HP, CPXHT 75)
Unit S/N / Compressor package serial number
Voltage Readings / Required on all claims with electrical component failure
Amp Readings / Required on all claims with motor failure
Ship Date / Date shipped from factory
Start Date / Commissioning Date of Package or Actual Invoice Date
Failure Date / Date when problem or occurrence occurred
Repair Date / Date package was repaired and put back in service
Total Hours / Total operating hours, required on all rotary screw compressor
Load Hours / On rotary compressors with controllers
All Motors Require Fault Notification Forms / Required on all motor failures from a motor repair facility.
Compressor Site Conditions / Completed for all installations (Pictures required if this could be an installation problem). No units outdoors without a cover.
Reported Problem / Problem with package reported by customer
Cause / What was the situation/component that caused the problem and what occurred with component to cause problem. Must have detailed analysis of situation that occurred.
Corrective Action / Complete detail of work required to complete repair and return the package to
Description, Article Number and Qty / List of all components used in the repair
Labor – Travel – On Site / Travel time from shop to customer location and hours to perform repair.
Rate / Distributor normal shop rate (this is paid at 70%)
Mileage / Mileage from shop to customer location ($0.65 per mile)
Miscellaneous Expenses / Complete explanation and invoices for review
Special Requirements for airend (element) failure / Oil Analysis completed before oil is changed in compressor
Completed Chicago Pneumatic Technical Airend (Element) Report
Special Requirements for any dryer failure / Completed Refrigerated Dryer Check for the type of failure (drain, compressor (including pressure switch), leaks of water carryover)
ALL CLAIMS MUST BE SUBMITTED WITHIN 30 DAYS
To: or Fax: (803) 817-7468
*Labor will be paid at 70% of Distributor published shop rate
V050103-UTO, Rev. 2, 3/2014 1 Ref.: V05-UTO