Product Warranty Program Request Form

Product Warranty Program Request Form
cynoSure Financial 33490 Harper Avenue, Clinton Township, MI 48035 586/771­3334 ­ Fax 586/771/4590 Email completed form to: [email protected] PRODUCT WARRANTY PROGRAM REQUEST FORM Submitted by: Name_________________________________________________________________________________ Company______________________________________________________________________________ Telephone No. ________________________________________________________________________ (Area Code) Item 1 Name_____________________________________________________________________________________ Address___________________________________________________________________________________ ___________________________________________________________zip _____________________ Description of Operations: ___________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Applicant is: Manufacturer Wholesaler Retailer Other ============================================================================================== Item 2 Describe the product that warranty coverage is needed for: _______________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Does Applicant currently issue a warranty on this product? Yes No Indicate number of years this warranty has been in use _________________________years. ATTACH COPY OF WARRANTY Does Applicant now have product warranty insurance with another carrier? Yes No If Applicant does not currently issue a warranty, clearly indicate coverage terms of proposed warranty. __________________________________________________________________________________________ _____________________________________________________________________________________________________________ __________________________________________________________________________________________
The Term “Product” as used in this Application may be substituted by “Service”. WRF 5_28_09 Item 3 Indicate annual total of all occurrences that could be considered warranty claims for prior years, whether or not the current warranty existed. Describe common defects occurring during each period. Year Amount Defect/Reason __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Has product ever been “recalled” for any reason? (If yes, please explain) Yes No __________________________________________________________________________________________ __________________________________________________________________________________________ Has product been modified within the last 5 years? (If yes, please explain) Yes No __________________________________________________________________________________________ __________________________________________________________________________________________ ============================================================================================== == Item 4 Indicate the unit price for this product/service. Retail $______________ Wholesale $_______________ If Applicant is a manufacturer, indicate per unit cost to manufacturer. $___________________________ Indicate past and projected units sold. Year Number of Units Sales Warranty Losses (if applicable) 2010_______________________________________________________________________________________________ 2011_______________________________________________________________________________________________ 2012_______________________________________________________________________________________________ 2013_______________________________________________________________________________________________ 2014 (Projected) _______________________________________________________________________________________ 2015 (Projected) ____________________________________________________________________________________________________________
The Term “Product” as used in this Application may be substituted by “Service”. WRF 5_28_09 Item 5 Has applicant entered into any hold/harmless or other contractual agreements which may relate to this? Warranty? (If yes, please explain) Yes No __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Indicate ultimate uses of this product. Individuals/Consumers ______________% Commercial _____________% If applicant is a manufacturer, do they have a quality control program for this product? (If yes, please explain) Yes No __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Indicate expected product life: __________________________years. Indicate product failure rate: ______________________________________ Is this product subject to government standards? (If yes, please explain) Yes No __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Desired Price / Pricing target for Warranty coverage $__________________________________________ Attach to Application: 1. Financial statements for the past three (3) years. This information may be submitted subsequent to this Application. 2. Product brochures, manuals, or other materials pertinent to this Application. ___________________________________________________________________ Applicant’s Signature / Date
The Term “Product” as used in this Application may be substituted by “Service”. WRF 5_28_09 
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