Product Concern Report

This document is to be used to report shortages, installation difficulties, product concerns, etc. encountered
during installation or servicing. Prompt reporting will enable us to address the situation quickly.

Model and Serial numbers MUST be provided.

_Model Number:____________________________________

Serial Number:_____________________________________

If the difficulty involves the power unit or parts box, the following numbers Must be provided:

Power unit serial number:________________________________________

Clock number from parts box load list:______________________________

Number from Bolt bag check list:__________________________________

Description of concern(s):

(_If additional space is required, please use separate sheet)

Container/Box Damaged:_________________________________________________________________
Installation Location: Name: ____________________________________________________________

Address:____________________________________________________________

City and State:____________________________________________________________

Submitted by:___________________________________________________ Date:__________________

Company:_____________________________________________________________________________

Phone Number:______________________________________ Fax:______________________________

Email address:_________________________________________________________________________

Please Print Clearly. For Prompt Attention,

Fax to 1.800.822.6502 or 812.273.6502 ATTN: Quality Department

Submit By Email