Warranty Claim Form

Warranty Claim Form
- This form is for Parts claims only - for part refund or part replacement requests.
- Failure to completely and accurately fill out this form will result in your claim being rejected until form is complete.
- The information below is required to lodge your claim with the manufacturer. Your claims cannot be submitted without these details.
- This completed form must be submitted together with the warranty part (return address below), along with the supporting documentation listed below.
- Required documentation to accompany the warranty part:
  MANDATORY:
  1. Copy of the Jefferson Ford parts invoice for the purchased part.
  IF APPLICABLE:
  1. Copy of the fitment invoice.
  2. Any failure reports or supporting documentation relevant to the claim.
Purchase Information
Return Authorisation Number
Name

First NameLast Name
Address

Street Address

Street Address Line 2

SuburbState

Post Code
Phone Number

Area CodePhone Number
Car Registration #
VIN #
Jefferson Ford Invoice #
Part Number
Part Description
Date of Purchase

DayMonthYear
Date
Date Part Fitted

DayMonthYear
Date
Date Part Failed

DayMonthYear
Date
Car kilometers at fitment
Car kilometers at failure
Describe the part issue
Presumed cause of failure
If the warranty is approved, you will be required to
Signature
Date Form Completed

DayMonthYear
Date
Should be Empty: