Claim Form Request

Store Name

First Name

Last Name

Your Name

First Name

Last Name

Manufacturer

Your Phone

(###)

###

####

Your Fax

(###)

###

####

Email

Please fill out a minimum of 1 of 4:

PO#

ACK#

Item#

Date Received

MM

DD

YYYY

Please fill out the required info above and a claim form will be sent to you within two business days. If you have any questions please call 800-876-1660 or e-mail freight@wiseway.com.