Claims FormPlease enable JavaScript in your browser to complete this form.Date *Business Name *Area Rep Name *Select Your Sales RepPeter Shleykher (North East)Cy Donaldson (Mid Atlantic)Walter Fitzgerald (South East)Eric Foley (Mid West)Jason White (South West)Jeff Lang (West Coast)Frank Russo (Canada)I Don't KnowAddress *USACanadaAddress *Address Line 1Address Line 2CityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCanada Address *Phone *Email *Order # *Original PO #End User Material Code *Description / Color *Size *Shade *Gage / Caliber *Disputed Quantity# of Pallets / # of Parcels *SF *Feet Linear *# of Items *Specific ComplaintMultiple Choice *Quality ComplaintShipping ComplaintQuality Complaint *Grade DefectsCleanabilityShadeSquarenessPlanarityPackagingGauge / CaliberOtherDescription *Shipping Complaint *Truck did not show upInventory ShortageOverage qty ShippedIncorrect ItemIncorrect CaliberIncorrect ShadeDamaged ProductC.S. ErrorOtherDescription *Complaint AmountOrder Total Amount *Claim Amount *ExplainCustomer ResolutionRequest *Damage CompensationTot. Discount on InvoicePart. Discount on InvoiceSolution to ProblemTot Replacement of MaterialPartial ReplacementOther NotesForm Completed By: *FirstLastSubmit