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PARTS AND LABOR REIMBURSEMENT AUTHORIZATION FORM
 
 
Please Fill This Form
 Shipping Information    
*Company Name
  
*Contact Name
  
*Address
  
*City
  
*State
  
*Zip
  
*Phone
  
e.g. 800-777-1234
*Fax
  
e.g. 800-777-1235
*Email
  
Needed to send your confirmation.
   
 
 Job Information
*HighMark Job Number: (information located on the label underneath the seat)
 
Problem Information
*Problem Statement
 
 
Optional Information
Upload Image(s): Use this option to provide pictures of the defective component(s).
File 1
File 2
File 3
File 4
File 5
     
 
     * Required field. RA process will be delayed without required information.
 
Labor reimbursement will be approved for up to 2 hours at $20 per hour and only apply to requests made within six months from the original ship date. Reimbursement does not include the drive time.
 

 
 

 
   
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