Tyre Claim
Claim/Adjustment Form
1).Claim no.
2).Date
Dealer
Name
Address
City
Postal Code
Customer
Name
Address
City
Postal Code
Vehicle
Registration No:
Model:
Meter Reading:
The form must be accurately completed and signed by the dealer. Incomplete claim forms will not be accepted Adjustments herein shall not be an admission of any liability and shall not be admissible in any proceedings
| No. | Brand. | Size | Pattern | DOT No. |
Reason for Failure |
Threat Debt - New Tyre |
Thread Debt - Returned Tyre |
FR/FL/RR/RL | Price | Discount % |
Credit |
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| 5. |
Note: Cut D.O.T. No.
Place of Inspection:
Inspected by:
Adjusted by:
Dealer's Signature :