Warranty & ESP® Claim Form - Pratt & Whitney Canada

* indicates mandatory fields
Date: _ _ _ _ _ _ _ _
Y M D
Claimant Company Information
Warranty & ESP ® Claim Form
Claimant Employee Information
Mail to: Pratt & Whitney Component Solutions
Warranty Administration
4905 Stariha Drive
Muskegon, MI 49441
Tel: 231-799-6620 Fax: 231-798-0150
Email: gp.pwc.muskegon.dpt@pwc.ca
*Company Name:____________________________________________
*Street Address:_____________________________________________
*City:_________________________ *ZIP/Postal Code:______________
State/Province:______________________________________________
*Country:___________________________________________________
*Name:___________________________________________________________
*Office Email Address:_______________________________________________
*Office Telephone Number:___________________________________________
Ext:_____________________________________________________________
Reference Number:________________________________________________
Engine Information
*Serial Number:__________________ *Engine Model:_________________________________________________
*Engine TSN:______________________________
*Event Date:____________________
ESP Work Authorization (WA) Number:_____________________________
Engine CSN:_____________________________
Engine Operator Name:________________________________________________________
ESP Contract Number:__________________________________
*Reason for Repair:_______________________________________________________________________________________________________________
Additional Event Information:
Parts Installed (*indicated mandatory if part is claimed)
*Part Condition
*Purchased From
QTY
*Installed
Part Number
Installed
Serial Number
New
Overhauled
Serviceable
PWCS/PDC
(Muskegon)
P&WC Head Office
(Longueuil)
Aviall
Other (Please
Specify)
*Invoice or PO
Number
Amount to be
Reimbursed (USD)
1
2
3
4
5
Parts Removed
*Disposal of Part
QTY
*Removed
Part Number
Removed
Serial Number
*Total TSN
Scrap Locally
Return Part
*Removed Part
Defect
Commercial Support
Program Number (if
applicable)
1
2
3
4
5
Labour (*indicates mandatory if labour is claimed)
Note: The standard P&WC Warranty hourly labour rate for inductions as of March 14, 2011 is $92 USD (prior $90 USD)
*Description of Labour
CSP Number (if
applicable)
*Labour Hours
*Hourly Labour Rate
(USD)
Total Amount
Other Allowances (*indicates mandatory if allowance is claimed)
*Description of Other Allowances
CSPN Number (if applicable)
*Amount to be
Reimbursed (USD)
Name of P&WC Representative involved in Engine Event (if applicable):
Other Information
*Form of Payment:
Credit Note
Check/Wire Transfer
*Note: P&WC reserves the right to determine final method of payment based on current account standing
P&WC 3090 (2011-03) WARRANTY (9411) 1

Warranty/ESP Form - Claim Instructions
Claimant Company Information
Enter the name and mailing address of the organization submitting the claim.
Claimant Employee Information
Enter the name, email address, and phone number of the personnel submitting the claim. It is important
to include contact phone number for communication. Provide a reference number to be used for
traceability.
Engine Information
Engine Model: Enter the type and model of the affected engine.
Event Date: Enter the date on which the engine event took place.
ESP Work Authorization Number (WA): If claiming against ESP, you must enter the Work Authorization
number you were provided at the time of event.
Time Since New, Cycles Since New: Enter engine total time in operation since new, and total cycles
operated since new at time of event.
Engine Operator Name: Enter the name of engine operator.
Reason for Repair: Enter a clear description of the reason for repair, the type of repair carried out, or the
maintenance action taken.
Additional Event Information:
Any additional information concerning the event being claimed may be provided here.
Parts Installed
Use a new line for each part. Enter the installed part number. If it is a serialized part, enter the part serial
number.
Check off the condition that best describes the installed part (new, serviceable).
Check off the source from which the installed parts are purchased.
Please provide an invoice number in accordance to the purchase of those parts.
Parts Removed
Enter the installed part number. If it is a serialized part, enter the part serial number.
Enter the engine’s total time in operation since new.
Check off the method in which the part is being disposed (scrap locally or return part).
Name the part defect (cracked, leaking, scratched, etc).
Labour
Enter the details regarding labour hours, labour rate, and description of labour carried out for this engine
event. Note: claims should be made in US funds.
Other Allowances
Enter the amount and details regarding additional reimbursement requested that are within the terms of
the applicable P&WC policy (e.g. miscellaneous parts, transportation, etc.) Note: claims should be made
in US funds.
Other Information
Check off the method in which you wish to receive your payment.
MAIL COMPLETED FORM TO THE AUTHORIZED SUPPLIER, FACILITY, OR
DISTRIBUTOR WHO HAS PROVIDED THE REPLACEMENT PARTS.
P&WC 3090 (2011-03) WARRANTY (9411) 2