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Claim Form

Ductless Heat Pump, OTP Series

Product serial number

Customer information
First Name:
Last Name:
Address:
City:
Province:
Postal Code:
Country:	Canada
Phone Number:
Email:
Installer information
Contractor ID:
Contractor:
Address:
City:
Province:
Postal Code:
Country:
Phone Number:
Email:
Product information
Product serial number – Indoor unit:
Product serial number – Outdoor unit:
Product Install Date:
Product type:
Number of indoor units:
Warranty Type:
Expiration:

Claim filled by:	ownerinstaller
Explanation of problem:

Description of repairs/labour performed	Repair code / hourly rate	Number of hours	Total cost f labour
	$		$
	$		$
	$		$
	$		$

Description of parts	Quantity	Cost	Process allowance*	Total cost of parts
		$	$	$
		$	$	$
		$	$	$
		$	$	$

*Parts are part of the original equipment manufacturer's warranty; the process allowance of parts is $35.00 per part replaced. For related work, the $35.00 process allowance can only be claimed on the primary part. Reimbursement of liquid refrigerant is fixed at $20.00 per pound.

Total cost of labour:	$
Total cost of parts:	$
Subtotal:	$
GST - Federal sales tax: %	$
PST - Provincial sales tax: %	$
HST - Harmonized sales tax: %	$
TOTAL:	$

Attach the repair work order, the invoice signed by the customer and the parts receipt:

All claims must be submitted within sixty (60) days of the failure date to be considered for reimbursement.

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