Purchaser's Information

First Name: Last Name:

Street Address:

City: State: Zip Code:

Home Phone: Cell Phone:

Work Phone: Email (Required):

Store of Purchase

Store Name:

Store Address: Phone #:

City: State: Zip:

Furniture Information

Fabric: Leather: Wood: Mattress: Mattress Pad:

Size: (Mattress or Mattress Pad)

Piece of Furniture: Manufacturer:

Price: Purchase Date(MM/DD/YYYY):

Delivery Date(MM/DD/YYYY):

Invoice#: Warranty Certificate #:

Serial/ ACK#: Style:

Cover: Color:

Cleaning Code (Fabric Only): S W WS X

Damage Description

Size of Damage: Locations Of Damage:

Explain in details the damage to the furniture:

Please check all parts that are removable:

Seat Cushions Only Back Cushions Only Seat And Back Cushions

Date of Incident(MM/DD/YYYY):

Please Explain in detail the incident that caused the damage:

If any efforts were made to correct the problem please explain.

	Left Facing Back Cushion
	Middle Facing Back Cushion
	Right Facing Back Cushion
	Right Facing Arm
	Left Facing Arm
	Left Facing Seat Cushion
	Middle Facing Seat Cushion
	Right Facing Seat Cushion
	Front Skirt or Front Rail

Please remember to complete the form in its entirety.
Incomplete claim forms will not be processed or serviced.