WARRANTY CLAIM FORM
1-5 WEARERS (ID#WR0205)
Who is filling out this form? (We'd like to contact you!)
*
Mr.
Mrs.
Miss
Prefix
First Name
Last Name
Company Name
*
Which company are the wearers from?
Email (Our first contact will be via email.)
*
Confirmation Email
example@example.com
Phone Number (We might need to call you during the process.)
*
Please enter a valid phone number.
Invoice Number
*
Please enter the invoice number/numbers on which the shoe/boot was issued.
Sales Order Number
*
Please enter the 5-digit number on the bottom of the white label on the front of your shoebox.
Fill in the names and genders of the wearers reporting defective footwear and the relevant information of the defective shoe/boot.
*
First & Last Name
Gender
Shoe Model
Colour
Size
Wearer No. 1
MALE
FEMALE
ARKANSAS
ASCENT
ASPHALT
AURELIUS
BAER
BAYONET
BEATRICE
BELGRADE
BELL
BENCH
BLANQUILLA
BOISE
BOONDOCK
BRADDOCK
BRANSTON
BRIGITTE
CHICAGO
CONCLUDE
CREGAN
DELFO
DELIA
DRUMSTEP
ELECTRICAL BIS
ELECTRICAL BLACK
ELENOIRE
ETHYL
FALCON
FLAMINGO
FREEPORT
FUNK
FURGLER
FUSE
GAMPER
GOLIAT
GIUDITTA
GRANT
GRENOBLE
HELIUM
HELIX
HELLCAT
HIGHTOWER
HULL BIS
HULL BLACK
HYPERCHARGE
ICARO
INGRID
INGRID US
KOLN
KNOX
LAND
LAND BIS
LEADER
LEADER BIS
LIQUID
LUGANO
MANITOBA
MONTI
MONTPELLIER
MOROTAI
NEWASPHALT
NEWBARENTS
NEWCIAD
NEW ELECTRICAL
OAKLAND
OVERPASS
OVERSEE
PAISLEY
PARKER MID
PIT BOSS
PUEBLO
RAP
RAPTOR
READY
RUHR
SECOND
SMALL BIS
SOLID
SPARROW
SQUAT
STEPPING
STOCKMAN
SUMATRA
SUTTON
TERAINA
TEX BIS
THERMIC
TIGER
TORCH
TRONCHETTO
TYPHOON
ULISSE
URANO
US ROAD
WANDA
WATFORD
WELDER BIS
WORTHING
BLACK
BROWN
BLUE
MULTI
Wearer No. 2
MALE
FEMALE
ARKANSAS
ASCENT
ASPHALT
AURELIUS
BAER
BAYONET
BEATRICE
BELGRADE
BELL
BENCH
BLANQUILLA
BOISE
BOONDOCK
BRADDOCK
BRANSTON
BRIGITTE
CHICAGO
CONCLUDE
CREGAN
DELFO
DELIA
DRUMSTEP
ELECTRICAL BIS
ELECTRICAL BLACK
ELENOIRE
ETHYL
FALCON
FLAMINGO
FREEPORT
FUNK
FURGLER
FUSE
GAMPER
GOLIAT
GIUDITTA
GRANT
GRENOBLE
HELIUM
HELIX
HELLCAT
HIGHTOWER
HULL BIS
HULL BLACK
HYPERCHARGE
ICARO
INGRID
INGRID US
KOLN
KNOX
LAND
LAND BIS
LEADER
LEADER BIS
LIQUID
LUGANO
MANITOBA
MONTI
MONTPELLIER
MOROTAI
NEWASPHALT
NEWBARENTS
NEWCIAD
NEW ELECTRICAL
OAKLAND
OVERPASS
OVERSEE
PAISLEY
PARKER MID
PIT BOSS
PUEBLO
RAP
RAPTOR
READY
RUHR
SECOND
SMALL BIS
SOLID
SPARROW
SQUAT
STEPPING
STOCKMAN
SUMATRA
SUTTON
TERAINA
TEX BIS
THERMIC
TIGER
TORCH
TRONCHETTO
TYPHOON
ULISSE
URANO
US ROAD
WANDA
WATFORD
WELDER BIS
WORTHING
BLACK
BROWN
BLUE
MULTI
Wearer No. 3
MALE
FEMALE
ARKANSAS
ASCENT
ASPHALT
AURELIUS
BAER
BAYONET
BEATRICE
BELGRADE
BELL
BENCH
BLANQUILLA
BOISE
BOONDOCK
BRADDOCK
BRANSTON
BRIGITTE
CHICAGO
CONCLUDE
CREGAN
DELFO
DELIA
DRUMSTEP
ELECTRICAL BIS
ELECTRICAL BLACK
ELENOIRE
ETHYL
FALCON
FLAMINGO
FREEPORT
FUNK
FURGLER
FUSE
GAMPER
GOLIAT
GIUDITTA
GRANT
GRENOBLE
HELIUM
HELIX
HELLCAT
HIGHTOWER
HULL BIS
HULL BLACK
HYPERCHARGE
ICARO
INGRID
INGRID US
KOLN
KNOX
LAND
LAND BIS
LEADER
LEADER BIS
LIQUID
LUGANO
MANITOBA
MONTI
MONTPELLIER
MOROTAI
NEWASPHALT
NEWBARENTS
NEWCIAD
NEW ELECTRICAL
OAKLAND
OVERPASS
OVERSEE
PAISLEY
PARKER MID
PIT BOSS
PUEBLO
RAP
RAPTOR
READY
RUHR
SECOND
SMALL BIS
SOLID
SPARROW
SQUAT
STEPPING
STOCKMAN
SUMATRA
SUTTON
TERAINA
TEX BIS
THERMIC
TIGER
TORCH
TRONCHETTO
TYPHOON
ULISSE
URANO
US ROAD
WANDA
WATFORD
WELDER BIS
WORTHING
BLACK
BROWN
BLUE
MULTI
Wearer No. 4
MALE
FEMALE
ARKANSAS
ASCENT
ASPHALT
AURELIUS
BAER
BAYONET
BEATRICE
BELGRADE
BELL
BENCH
BLANQUILLA
BOISE
BOONDOCK
BRADDOCK
BRANSTON
BRIGITTE
CHICAGO
CONCLUDE
CREGAN
DELFO
DELIA
DRUMSTEP
ELECTRICAL BIS
ELECTRICAL BLACK
ELENOIRE
ETHYL
FALCON
FLAMINGO
FREEPORT
FUNK
FURGLER
FUSE
GAMPER
GOLIAT
GIUDITTA
GRANT
GRENOBLE
HELIUM
HELIX
HELLCAT
HIGHTOWER
HULL BIS
HULL BLACK
HYPERCHARGE
ICARO
INGRID
INGRID US
KOLN
KNOX
LAND
LAND BIS
LEADER
LEADER BIS
LIQUID
LUGANO
MANITOBA
MONTI
MONTPELLIER
MOROTAI
NEWASPHALT
NEWBARENTS
NEWCIAD
NEW ELECTRICAL
OAKLAND
OVERPASS
OVERSEE
PAISLEY
PARKER MID
PIT BOSS
PUEBLO
RAP
RAPTOR
READY
RUHR
SECOND
SMALL BIS
SOLID
SPARROW
SQUAT
STEPPING
STOCKMAN
SUMATRA
SUTTON
TERAINA
TEX BIS
THERMIC
TIGER
TORCH
TRONCHETTO
TYPHOON
ULISSE
URANO
US ROAD
WANDA
WATFORD
WELDER BIS
WORTHING
BLACK
BROWN
BLUE
MULTI
Wearer No. 5
MALE
FEMALE
ARKANSAS
ASCENT
ASPHALT
AURELIUS
BAER
BAYONET
BEATRICE
BELGRADE
BELL
BENCH
BLANQUILLA
BOISE
BOONDOCK
BRADDOCK
BRANSTON
BRIGITTE
CHICAGO
CONCLUDE
CREGAN
DELFO
DELIA
DRUMSTEP
ELECTRICAL BIS
ELECTRICAL BLACK
ELENOIRE
ETHYL
FALCON
FLAMINGO
FREEPORT
FUNK
FURGLER
FUSE
GAMPER
GOLIAT
GIUDITTA
GRANT
GRENOBLE
HELIUM
HELIX
HELLCAT
HIGHTOWER
HULL BIS
HULL BLACK
HYPERCHARGE
ICARO
INGRID
INGRID US
KOLN
KNOX
LAND
LAND BIS
LEADER
LEADER BIS
LIQUID
LUGANO
MANITOBA
MONTI
MONTPELLIER
MOROTAI
NEWASPHALT
NEWBARENTS
NEWCIAD
NEW ELECTRICAL
OAKLAND
OVERPASS
OVERSEE
PAISLEY
PARKER MID
PIT BOSS
PUEBLO
RAP
RAPTOR
READY
RUHR
SECOND
SMALL BIS
SOLID
SPARROW
SQUAT
STEPPING
STOCKMAN
SUMATRA
SUTTON
TERAINA
TEX BIS
THERMIC
TIGER
TORCH
TRONCHETTO
TYPHOON
ULISSE
URANO
US ROAD
WANDA
WATFORD
WELDER BIS
WORTHING
BLACK
BROWN
BLUE
MULTI
Fill in the department and job title of each wearer and indicate if the wearer is on a shift.
*
Department
Job Title
Shift Worker
Wear Period
Wearer No. 1
YES
NO
LESS THAN 1 WEEK
7-15 DAYS
15-30 DAYS
MORE THAN 1 MONTH
Wearer No. 2
YES
NO
LESS THAN 1 WEEK
7-15 DAYS
15-30 DAYS
MORE THAN 1 MONTH
Wearer No. 3
YES
NO
LESS THAN 1 WEEK
7-15 DAYS
15-30 DAYS
MORE THAN 1 MONTH
Wearer No. 4
YES
NO
LESS THAN 1 WEEK
7-15 DAYS
15-30 DAYS
MORE THAN 1 MONTH
Wearer No. 5
YES
NO
LESS THAN 1 WEEK
7-15 DAYS
15-30 DAYS
MORE THAN 1 MONTH
What are the working conditions of the wearers? Check all that apply.
*
Wearer No. 1
Wearer No. 2
Wearer No. 3
Wearer No. 4
Wearer No. 5
Cement
Chemicals
Cut Hazards
Driving
Dry Warehouse
Extended Water Contact
Lengthy Standing Period
Puncture Hazards
None of the Above
Put any further information about the wearer's work conditions below.
Is the defective footwear still being worn?
*
Yes
No
Upload a clear picture of the shoe defect here. (One picture per defective shoe.)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Put any further information about the shoe defect below.
Upload a clear, close-up picture of the label on the tongue of the shoe here. (One picture per defective shoe)
Browse Files
Drag and drop files here
Choose a file
Choose the tongue of any foot of the pair for the picture. The text on the label should be legible.
Cancel
of
Upload a picture of the front of the box that the shoe came in, clearly showing the box labels. (One picture per defective shoe)
Browse Files
Drag and drop files here
Choose a file
The front of the box is where the name of the shoe is.
Cancel
of
Are you one of the wearers?
*
Yes
No
Desired remedy
*
Replacement of same model and size (free of charge)
Full refund (applicable only if return is made within 20 days of the purchase)
Exchange for a different model or size (any price difference will be paid by the customer)
Store credit for the full value of the returned item
Submit
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