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Appendix A Warranty Claim Form
Irbit Motorworks of America, Inc.
Dealer_________________ ______Authorized #___________Date/__/__/__/
Motorcycle Information
VIN # /__/__/__/__/__/__/__/__/__/__/__/__/__/__/__/__/__/
Engine /__/__/__/__/__/__/ Gearbox /__/__/__/__/__/__/ Model ____________ Mileage (km)_________
Owner’s Name______________________ Date of Registration /___/___/___/
Complete
Address___________________________________________________________________________
Comments_________________________________________________________________________________
Service Information
Technician__________________Start Date /___/___/___/ Completion Date /___/___/___/
Diagnosis of Defect________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________
Part # Description Qty Dlr. Cost
____________________ ______________________ ______ _________
____________________ ______________________ ______ _________
____________________ ______________________ ______ _________
____________________ ______________________ ______ _________
____________________ ______________________ ______ _________
____________________ ______________________ ______ _________
____________________ ______________________ ______ _________
Parts Total $__________
All warranty parts are shipped using standard UPS ground only.
Flat Rate Schedule: Check the items that pertain to this claim.
1. Engine 2. Gearbox 3. Final Drive 4. Front Fork 5. Wheel & Tire
1.1 __ 1.4hr 1.7 __ 0.1hr 2.1 ___ 0.5hr 3.1 ___ 0.3hr 3.7 ___ 0.3hr 4.1 ___0.7hr 5.1 ___ 0.2hr
1.2 __ 1.5hr 1.8 __ 0.1hr 2.2 ___ 0.1hr 3.2 ___ 0.4hr 3.8 ___ 0.2hr 4.2 ___ 0.5hr 5.2 ___ 0.2hr
1.3 __ 2.0hr 1.9 __ 0.7hr 2.3 ___ 0.9hr 3.3 ___ 0.6hr 4.3 ___ 0.5hr 5.3 ___ 0.4hr
1.4 __ 1.5hr 1.10 __ 0.4hr 2.4 ___ 1.2hr 3.4 ___ 0.7hr 4.4 ___ 0.4hr 5.4 ___ 0.3hr
1.5 __ 0.2hr 1.11 __ 0.3hr 2.5 ___ 0.4hr 3.5 ___ 0.7hr 5.5 ___ 0.3hr
1.6 __ 0.1hr 1.12 __ 0.4hr 3.6 ___ 0.9hr 5.6 ___ 0.2hr
1.13 __ 0.3hr
6. Sidecar 7.Chassis 8. Electrical
6.1 ___0.3hr 6.5 ___ 0.2hr 7.1 ___ 0.3hr 7.5 ___ 0.2hr 8.1 ___ 0.6hr 8.5 ___ 0.2hr 8.9 ___ 0.3hr
6.2 ___ 0.1hr 6.6 ___ 0.2hr 7.2 ___ 0.5hr 7.6 ___ 0.2hr 8.2 ___ 0.4hr 8.6 ___ 0.3hr 8.10 ___ 0.1hr
6.3 ___ 0.3hr 6.7 ___ 0.4hr 7.3 ___ 0.4hr 7.7 ___ 0.4hr 8.3 ___ 1.2hr 8.7 ___ 0.2hr 8.11 ___ 0.2hr
6.4 ___0.4hr 7.4 ___ 0.3hr 7.8 ___ 0.2hr 8.4 ___ 0.6hr 8.8 ___ 0.1hr
Labor Information
Flat Rate Hours_______________ Shop Rate $_______________Total $_____________
Dealer Signature_________________________ Date_________
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