Boiler Leak Claim Form

Please fill out as completely as possible and include pictures of the affected area as well as a copy of the Bill of Sale.

Date(Required)

Who is filling out this form

I am the customer

I am the dealer, filling it out for a customer

I am a dealer, filling it out for myself

Dealer Information

Distributor / Dealer Name(Required)

Distributor / Dealer Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Distributor / Dealer Phone Number

Distributor / Dealer Fax Number

Distributor / Dealer Email

Customer Information

Customer Name(Required)

Customer Physical Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Customer Daytime Phone Number(Required)

Customer Fax Number

Customer Email

Stove Information

Model(Required)

Serial Number (S/N)(Required)

Purchase Date(Required)

Install Date(Required)

Description of Claim(Required)

Have you turned in a warranty claim before?(Required)

Yes

Is the leak in the same place?

Yes

Additional Notes or Comments

Repair Required(Required)

Photo Upload of Area Needing Repair

Drop files here or

Max. file size: 512 MB, Max. files: 5.

Please also include a copy of the bill of sale. If a video of the leak is available, please send it to service@green-techmfg.com with your name and stove serial number included in the e-mail.