Warranty Claim Form

General Information

Name: *

Company Name: *

Address 1: *

Address 2:

City: *

State: *

Zip Code: *

Phone: *

Fax:

Email: *

I am a: *

Jobsite Information

Information regarding the location where the ballasts are installed.

Company Name:

Address 1: *

Address 2:

City: *

State: *

Zip Code: *

Key Contact Person: *

Phone: *

Fax:

Email: *

Type of Installation

Select Type: *

Original Installation (installed within fixture upon purchase)

After-market installation (replacement of an original ballast)

Retrofit

Ballast Information

Catalog No. (indicated on ballast label): *

Total No. of Ballasts at Jobsite: *

Quantity of Ballasts Not Working: *

Date of First Failure: *

Date Installed: *

Date Code on Ballast:

Printed on the side of the ballast. See our warranty page for more information.

Nature of Problem: *

Fixture Information

Manufacturer Name:

Type of Fixture:

Date of Fixture Installation: *

Installation Location: *

Comments: