Picote Service Request

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Reason for Claim

Reason for claim*

i.e. Part replacement under warranty, Part replacement outside warranty, item missing from order, wrong item delivered/ordered

Contact Information

Form Completed By*

Company Name*

Company Name

Reseller or Service Center Company Name*

Company Name

Contact Name*

First Name

Last Name

Phone Number*

Email*

example@example.com

Additional Email

No Yes

F.e. Supervisor email

Email 2*

example@example.com

Do you want the part to be shipped to a different address?

No Yes

F.e. Different warehouse or directly to the end user

Shipping Address

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

Other Information

Reseller Sales Person

First Name

Last Name

Order Number*

Reseller or Picote Order Number

Was this purchased within the past 12 months?*

Yes No

Copy of Receipt / Invoice

No File Chosen

File uploads may not work on some mobile devices.

Receipt/Invoice required for warranty claims

List of missing, damaged or incorrect items

Please write a list of missing / incorrect items or attach a file with missing / incorrect items listed.

Do you want to attach a file or write a list?*

Attach a file Write a list

File*

No File Chosen

File uploads may not work on some mobile devices.

Attach a file listing missing, damaged or incorrect items

List of items*

Remember to add item quantity

How many files/pictures do you have of damaged items or packaging*

File 1*

No File Chosen

File uploads may not work on some mobile devices.

File 2*

No File Chosen

File uploads may not work on some mobile devices.

File 3*

No File Chosen

File uploads may not work on some mobile devices.

File 4*

No File Chosen

File uploads may not work on some mobile devices.

File 5*

No File Chosen

File uploads may not work on some mobile devices.

File 6*

No File Chosen

File uploads may not work on some mobile devices.

File 7*

No File Chosen

File uploads may not work on some mobile devices.

File 8*

No File Chosen

File uploads may not work on some mobile devices.

File 9*

No File Chosen

File uploads may not work on some mobile devices.

File 10*

No File Chosen

File uploads may not work on some mobile devices.

Product Details

Type of Equipment*

Product Name*

i.e. Maxi Miller, Mini Pump, Mini Cleaner, Original Chain DN100

Serial Number*

Machine serial number

What was the power source for the equipment when you experienced the problem?*

i.e. Generator type, 110v, etc.

Product Number

Picote or Reseller product/part number

Description of fault

Describe the fault / what symptoms are being experienced?*

(Noise, shake, overheating, cable twisting, etc.)

Describe the job being performed when the fault appeared.*

i.e. Liner removal, coating, etc.

Estimated total usage of the tool / machine.*

Number of hours

How long was the tool used for before the fault appeared?*

i.e. 30 mins, 3 hours, etc.

Was the operator trained for the usage of the equipment?*

Yes No

Has repair been attempted already?

No Yes

What was attempted?

Other remarks?

Additional description of the issue.

How many files/pictures do you have of fault / equipment?*

File 1*

No File Chosen

File uploads may not work on some mobile devices.

File 2*

No File Chosen

File uploads may not work on some mobile devices.

File 3*

No File Chosen

File uploads may not work on some mobile devices.

File 4*

No File Chosen

File uploads may not work on some mobile devices.

File 5*

No File Chosen

File uploads may not work on some mobile devices.

Service Information

Date/Time*

Product Name*

Monitor name

Product Number*

Serial Number

Maxi Miller, Mini Pump, etc.

Name*

First Name

Last Name

Hours of Service*

Claim Summary*

i.e. Description of fault or issue

How many parts replaced?*

Replaced part 1*

Product Number

Replaced part 2*

Product Number

Replaced part 3*

Product Number

Replaced part 4*

Product Number

Replaced part 5*

Product Number

Replaced part 6*

Product Number

Replaced part 7*

Product Number

Replaced part 8*

Product Number

Replaced part 9*

Product Number

Replaced part 10*

Product Number

Replaced part 11*

Product Number

Replaced part 12*

Product Number

Replaced part 13*

Product Number

Replaced part 14*

Product Number

Replaced part 15*

Product Number

Replaced part 16*

Replaced part 17*

Replaced part 18*

Replaced part 19*

Replaced part 20*

Replaced part 21*

Replaced part 22*

Replaced part 23*

Replaced part 24*

Replaced part 25*

Warranty (confirmation)

Name*

First Name

Last Name

Is warranty valid?*

Yes No