Warranty Claim Form

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Claim Date *

Retailer Name

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email *

Contact Person

Phone *

Name *

First

Last

Purchase Date *

Bicycle Model

Frame / Serial

Battery Number

Battery Voltage

Service Date

Speedometer *

Is this a controller fault? *

Controller Type

Controller Serial Number

Fault; Diagnosis *

Parts Affected *

Comment

File Upload 01

Upload or attach a photo or document for the warranty claim ie photo of frame number, purchase doc

File Upload 02

Upload or attach a photo or document for the warranty claim ie photo of frame number, purchase doc

File Upload 03

Upload or attach a photo or document for the warranty claim ie photo of frame number, purchase doc

Name