JX Warranty Claim Form

JX Warranty Claim Form-2017-R2

JX Warranty Claim Form

"*" indicates required fields

Customer Information

Sponsoring Branch*

Fleet Name*

Account Number*

Fleet Contact Name*

Phone*

Email*

Vehicle Information

Work Order/ RO#*

Date of Failure*

Make*

Mileage @ Time of Failure*

Vehicle Serial Number*

Complaint

Cause

Investigation

Correction

Claim Information

Total Repair Hours Claimed

Labor Rate per/hr

Parts

Number

Description

Qty

Price Ea.

Total

Sublet Invoice Info

Parts

$ Amt (USD)

Description

Total Labor

Total Parts

Total Sublet

Claim Total

Attach Supporting Files

File

Drop files here or

Accepted file types: pdf, docx, jpg, png, doc, gif, Max. file size: 200 MB, Max. files: 10.

Signature

SMS Policy

I agree to the privacy policy.

I consent to receive SMS from JX Enterprises, Inc. You may receive text messages related to orders, deliveries, repair status, and general inquiries. Reply STOP to opt-out; Reply HELP for assistance; Message and data rates apply; Messaging frequency may vary. For full Privacy Policy and Terms of Use please visit https://jxtruckcenter.com/privacy-policy.

By submitting this form, you consent to JX Enterprises contacting you via phone, or email.

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JX Warranty Claim Form