Warranty Claim For Payment Request

TLRV
111 East Innovation Blvd Syracuse, IN 46567 P: (574) 457-3924 Ext-123 Email: Warranty@tlrvs.com

Warranty Claim For Payment Request
Dealer Name
Dealer Work Order#
Dealer Address
Unit Vin#
TLRV Preauthorization#
Requestor/Dealer Email
example@example.com
Requestor Name
Date Work Performed

MonthDayYear
Date
Requestor/Dealer Phone#
Dealer PO/WO#
Date Req

MonthDayYear
Date
Total Hours on Claim
Labor Rate per Hour
Total Labor Requested

Parts and Shop Supplies

Rows	Part/Supply Used	Description	Qty	Cost/Per	Extended
n/a
n/a
n/a
n/a
n/a
n/a

Any service or repair to be provided or rendered outside of an approved TLRV dealer, must be authorized by TLRV prior to work being done. Copy of invoice must be provided along with the claim form for reimbursement
Entity Name
Inv#
Inv Amount
Total Warranty Claim Requested
Should be Empty: