Unbalanced Warranty Claim FormPlease enable JavaScript in your browser to complete this form. - Step 1 of 4Total Claim Ref # *This is your reference number.Date *Dealer Claim # *Total Tire Invoice # *Territory Manager *NextDealer InformationDealer Name *Store Name *Email *This email will be used to contact you regarding your warranty status.Store Address *Address Line 1CityState / Province / RegionPostal CodePhone *PreviousNextVehicle InformationVehicle (Year/Make/Model) *FirstMiddleLastTire Install DateTire Install KM *Tire Removal KM *Total KM *Original Equipment? *YesNoPreviousNextClaim InformationTire Manufacturer *Item # *Pattern *Tire Width *Tire Profile *Wheel Size *Dot Number *RTD/32 *Quantity Weight Used to BalanceReason For Failure/Claim Code1. Out of Round1. Out of Round2. Seperation3. Mileage4. Road Hazard5. Other (Please Explain Below)Reason For Failure - OtherPlease complete this if you've chosen "Other" as the Reason For Failure.Picture Upload * Click or drag files to this area to upload. You can upload up to 10 files. THE FOLLOWING PHOTOS MUST BE PROVIDED TO PROCESS WARRANTIES: Side Wall Front, Side Wall Rear, Tread, Proof of Purchase, Dot, Damaged Area (If Applicable), RTDSubmit
