Warranty Claim Form

Warranty Claim Form

Venture Medical ReQuip
1. Only one claim per submission will be processed. Submit one form for each item claim.

2. Picture of the claim is mandatory for warranty consideration.

3. Venture Medical reserves the right to deny any claim request that is not within the terms of sale.

Helpful Hint for uploading images:

If you are filling this form out on a desktop and want to add a photo from your mobile device, simply save the form (button at bottom of form). An email will be sent to the email address you provided that will have a link to continue your submission. Open the email with your mobile device, click on the link, and then you may scroll to the image upload section to complete the submission.
Purchase Information
Purchase Date

MonthDayYear
Purchase Order#
Leave blank if no purchase order was submitted
Venture Medical INV#
Typically the invoice number will be formatted as 000000-00
Product MFG
Product Model
Product Serial #
Type NA if you cannot locate SN
Describe the issue(s)
Claim Picture

Cancelof
Customer Details
Company Name
Contact Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
You will typically receive a reply within 2 business days (excluding weekends and holidays).

You will receive a confirmation email shortly after submission. If you do not receive a confirmation within 15 minutes, please try again, or use our general contact form.
Should be Empty:

Warranty Claim Form

Purchase Information

Customer Details