First, complete at least the required (*) fields in the form below.
*Must check one
(Enter number only)*RMA#  m *Serial # Sales Order #

Claimant Information
*Name   (First and Last Name)
*Address *City/State *Zip Code
*Phone Number *E-Mail    

Purchase Information
*Store Name *Store No. Purchase Date
Mileage at Install: Current Mileage  

Vehicle Information
*Year *Make *Model *Engine Size
*VIN#  
Transmission Part#  Transmission Type: 

Claim Details (At least one line must be filled out completely, quantity., description and total claim) 
*Quantity *Description of labor or part *Total
  Total
Labor will only be reimbursed for repairs completed by a professional repair facility; Repair Orders from the repair facility must be submitted with the labor reimbursement request for processing. All labor reimbursement amounts are determined from warranty time hours in the current ALL DATA time guide at the rate of $50.00 per hour with the maximum labor cap indicated in your warranty documentation. Where applicable, transmission fluid will be reimbursed up to a rate of $20.00 per claim. Complete unit replacement claims will only be reimbursed when the alleged defective unit is returned and found to have failed due to a factory related issue. Field Repair reimbursement claims will be processed once the defective part(s) are returned unless otherwise noted by your Warranty Administrator.

Upon submission of a labor reimbursement request, you release Moveras, LLC and their distributors from any further liability regarding this warranty return.
The form may take up to a minute to process.. please be patient.
*Sign Date    

FOLLOWING IS FOR MOVERAS USE ONLY
    Date Received
All Data Warranty Hours Approved Reimbursement Amount
Evaluation Disposition
Warranty Administrator
Approved By Date

If not submitting this form electronically......................................................................................................... This form may be faxed to: (603) 685-6883
This form may be emailed to: techsupport@moveras.com
This form may be mailed to: Moveras, LLC
22 Northwestern Drive
Salem, NH 03079