LX Hausys Claim Form

Retailer Information

Name:

Address:

Phone:

Email:

Date Reported to Retailer:

Inspection Date:

Distributor PO#:

Distributor Item #:

Material Lot #:

Site Information

Name:

Address:

Phone:

Email:

Delivery Date to Job Site:

Installationn Date:

Date Problem Noticed:

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Reason For Claim:

Quantity of Material Considered Defective:

What is the Dealer or Consumer Requesting?

Affected Material Cost:

Replacement Labor Cost of Affected Material:

Inspection Report

Present at Inspection

Site Information:

HVAC Information CentralZoned

Heating Type: GasElectric

Room Conditions:

Temperature:°F

RH:%

Product and Installation Information:

Description:

Style:

Installation Method FloatingGlue DownLoose Lay

Adhesive Used if Glue Down:

Subfloor: ConcretePlywood

Use: Heavy CommercialLight CommercialResidential

Wheeled/rolling traffic: YesNo

Location of Flooring:

New Construction: YesNo

Previous Floorings Type:

Was Previous Flooring Removed: YesNoN/A

Moisture Testing:

Meter Used:

Moisture readings:

Other Reported Concerns:

Other Reported Concerns:

Claim History:

Claim History:

Physical Descriptions / Observations:

Physical Descriptions / Observations:

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