Modern Supply Middlebrook Warranty Claim Form
Please provide details about the equipment, parties involved, and the issue for prompt assistance.
Distributor Name
*
Dealer or Contractor Name
*
Dealer Contact Email
*
example@example.com
Dealer Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Home Owners First And Last Name
*
Home owners Address
*
Equipment Model
*
Equipment Serial Number
*
Failed Part Number(s)
*
Please select if Coil Or compressor
Coil
Compressor
Failed Coil/Compressor Model
Replacement Coil/Compressor Model
Failed Coil/Compressor Serial
Replacement Coil/Compressor Serial
Invoice Number
*
Installation Date
-
Month
-
Day
Year
Date
Failure Date
-
Month
-
Day
Year
Date
Reason for Failure
Submit
Should be Empty: