Date*

Store name*

Contact Address*
Street*

City*

State*

Zip Code*

Account Number*

Contact Name*

Contact Email Address*

Contact Phone Number*

Consumer Name*

Consumer Address*
Street*

City*

State*

Zip Code*

Consumer Phone Number*

Alternate Phone Number*

Consumer Email Address*

Product Installed*

Date Installed*

Date Noticed*

Product Invoice Number*

Type of Subfloor*

Room(s) Where Installed*

Quantity Installed*

Quantity Affected*

Describe the issue reported by the consumer*:

Requested Action*:

Upload Photos*: Please attach a minimum of three photos showing reported concern when submitting claim. (Accepted file types: jpg, png, gif, pdf)

Upload Invoices*: Please include copies of invoices showing material purchase. These must be included. (Accepted file types: jpg, png, gif, pdf)