C&C Claim Form

C&C Wholesale Distributors

Email Address:

C&C Claim #:

C&C Sales Rep Name:

Dealer Name: *

Dealer Account #:

Dealer City & State:

Dealer Contact Name:

Dealer Contact Phone #:

Product Manufacturer:

Job Sidemark/Purchase Order #:

End User Address:

C&C Invoice #:

Product Name/Item #:

Product Batch/Dye Lot #:

Amount of SF/SY Installed:

Date Installed:

Date of Complaint:

Mortars & Adhesives Used:

Moisture Reading:

Nature of Complaint:

Dealer is Asking For?: