{"id":2770,"date":"2023-01-04T23:04:01","date_gmt":"2023-01-04T23:04:01","guid":{"rendered":"https:\/\/tdsautoparts.ca\/?page_id=2770"},"modified":"2023-01-10T23:20:58","modified_gmt":"2023-01-10T23:20:58","slug":"tds-warranty-claim-form","status":"publish","type":"page","link":"https:\/\/tdsautoparts.ca\/?page_id=2770","title":{"rendered":"TDS Warranty Claim Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"2770\" class=\"elementor elementor-2770\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-6abe7d5 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"6abe7d5\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-54b591a\" data-id=\"54b591a\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-2ac49e5 elementor-widget elementor-widget-heading\" data-id=\"2ac49e5\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Apply for your TDS Auto Parts Warranty Claim using this form<\/h1>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-35bcd33 elementor-widget elementor-widget-text-editor\" data-id=\"35bcd33\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<p>Please try to provide as much information as possible to ensure a smooth and quick turnaround. DO NOT send any parts for warranty without getting a Return Warranty Authorization (RWA) number from TDS Auto Parts. \u00a0Our promise to you: The information you supply to us will not be sold or provided to outside agencies. It will only be used to enable TDS Auto Parts to serve you, our customer, better.<\/p>\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-54a9415 elementor-widget elementor-widget-shortcode\" data-id=\"54a9415\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-shortcode\"><div class=\"forminator-ui forminator-custom-form forminator-custom-form-2769 forminator-design--material forminator-enclosed forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-2769\" data-uid=\"6a6d38243145c\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-2769\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-2769 forminator-design--material forminator-enclosed forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"2769\"\n\t\t\t\tenctype=\"multipart\/form-data\" data-color-option=\"default\" data-design=\"material\" data-grid=\"enclosed\" style=\"display: none;\"\n\t\t\t\tdata-uid=\"6a6d38243145c\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_6a6d38243145c\" id=\"forminator-field-email-1_6a6d38243145c-label\" class=\"forminator-label\">Email <span class=\"forminator-required\">*<\/span><\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_6a6d38243145c\" class=\"forminator-input forminator-email--field\" data-required=\"1\" aria-required=\"true\" autocomplete=\"email\" aria-describedby=\"forminator-field-email-1_6a6d38243145c-description\" \/><span id=\"forminator-field-email-1_6a6d38243145c-description\" class=\"forminator-description\">If you are a customer, enter in your e-mail address. If you are a dealer, enter in the dealer e-mail address. This e-mail address will be used for all communication regarding this submission.<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"group-1\" class=\"forminator-field-group forminator-col forminator-col-6 \"><label class=\"forminator-label forminator-repeater-label\">Client Information<\/label><div class=\"forminator-all-group-copies forminator-repeater-field\"><div class=\"forminator-grouped-fields\" data-options=\"{&quot;is_repeater&quot;:false,&quot;min_type&quot;:&quot;custom&quot;,&quot;max_type&quot;:&quot;custom&quot;,&quot;min&quot;:1,&quot;max&quot;:9223372036854775807,&quot;add_text&quot;:&quot;Add item&quot;,&quot;remove_text&quot;:&quot;Remove item&quot;,&quot;action_element_type&quot;:&quot;button&quot;}\"><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_6a6d38243145c\" id=\"forminator-field-name-1_6a6d38243145c-label\" class=\"forminator-label\">Contact Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"\" id=\"forminator-field-name-1_6a6d38243145c\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_6a6d38243145c\" id=\"forminator-field-text-1_6a6d38243145c-label\" class=\"forminator-label\">Company Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_6a6d38243145c\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_6a6d38243145c\" id=\"forminator-field-phone-1_6a6d38243145c-label\" class=\"forminator-label\">Phone Number <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_6a6d38243145c\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1\" class=\"forminator-field-address forminator-col forminator-col-12 \"><div class=\"forminator-row\"><div id=\"address-1-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-street_address_6a6d38243145c\" id=\"forminator-field-address-1-street_address_6a6d38243145c-label\" class=\"forminator-label\">Street Address <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-1-street_address\" placeholder=\"\" id=\"forminator-field-address-1-street_address_6a6d38243145c\" class=\"forminator-input\" data-required=\"1\" aria-required=\"true\" autocomplete=\"address-line1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1-address_line\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-address_line_6a6d38243145c\" id=\"forminator-field-address-1-address_line_6a6d38243145c-label\" class=\"forminator-label\">Apartment, suite, etc<\/label><input type=\"text\" name=\"address-1-address_line\" placeholder=\"\" id=\"forminator-field-address-1-address_line_6a6d38243145c\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line2\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"address-1-city\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-city_6a6d38243145c\" id=\"forminator-field-address-1-city_6a6d38243145c-label\" class=\"forminator-label\">City <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-1-city\" placeholder=\"\" id=\"forminator-field-address-1-city_6a6d38243145c\" class=\"forminator-input\" data-required=\"1\" aria-required=\"true\" autocomplete=\"address-level2\" value=\"\" \/><\/div><\/div><div id=\"address-1-state\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-state_6a6d38243145c\" id=\"forminator-field-address-1-state_6a6d38243145c-label\" class=\"forminator-label\">Province <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-1-state\" placeholder=\"\" id=\"forminator-field-address-1-state_6a6d38243145c\" class=\"forminator-input\" data-required=\"1\" aria-required=\"true\" autocomplete=\"address-level1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"address-1-zip\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-zip_6a6d38243145c\" id=\"forminator-field-address-1-zip_6a6d38243145c-label\" class=\"forminator-label\">Postal Code <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-1-zip\" placeholder=\"\" id=\"forminator-field-address-1-zip_6a6d38243145c\" class=\"forminator-input\" autocomplete=\"postal-code\" value=\"\" \/><\/div><\/div><div id=\"address-1-country\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-2769__field--address-1-country_6a6d38243145c\" id=\"forminator-field-2769__field--address-1-country_6a6d38243145c-label\" class=\"forminator-label\">Country <span class=\"forminator-required\">*<\/span><\/label><select name=\"address-1-country\" id=\"forminator-field-2769__field--address-1-country_6a6d38243145c\" class=\"forminator-select2\" data-search=\"true\" data-placeholder=\"Select country\" autocomplete=\"country-name\" data-default-value=\"Canada\"><option value=\"\" data-country-code=\"\" selected=\"selected\"><\/option><option value=\"Afghanistan\" data-country-code=\"AF\" >Afghanistan<\/option><option value=\"Albania\" data-country-code=\"AL\" >Albania<\/option><option value=\"Algeria\" data-country-code=\"DZ\" >Algeria<\/option><option value=\"American Samoa\" data-country-code=\"AS\" >American Samoa<\/option><option value=\"Andorra\" data-country-code=\"AD\" >Andorra<\/option><option value=\"Angola\" data-country-code=\"AO\" >Angola<\/option><option value=\"Anguilla\" data-country-code=\"AI\" >Anguilla<\/option><option value=\"Antarctica\" data-country-code=\"AQ\" >Antarctica<\/option><option value=\"Antigua &amp; Barbuda\" data-country-code=\"AG\" >Antigua &amp; Barbuda<\/option><option value=\"Argentina\" data-country-code=\"AR\" >Argentina<\/option><option value=\"Armenia\" data-country-code=\"AM\" >Armenia<\/option><option value=\"Aruba\" data-country-code=\"AW\" >Aruba<\/option><option value=\"Ascension Island\" data-country-code=\"AC\" >Ascension Island<\/option><option value=\"Australia\" data-country-code=\"AU\" >Australia<\/option><option value=\"Austria\" data-country-code=\"AT\" >Austria<\/option><option value=\"Azerbaijan\" data-country-code=\"AZ\" >Azerbaijan<\/option><option value=\"Bahamas\" data-country-code=\"BS\" >Bahamas<\/option><option value=\"Bahrain\" data-country-code=\"BH\" >Bahrain<\/option><option value=\"Bangladesh\" data-country-code=\"BD\" >Bangladesh<\/option><option value=\"Barbados\" data-country-code=\"BB\" >Barbados<\/option><option value=\"Belarus\" data-country-code=\"BY\" >Belarus<\/option><option value=\"Belgium\" data-country-code=\"BE\" >Belgium<\/option><option value=\"Belize\" data-country-code=\"BZ\" >Belize<\/option><option value=\"Benin\" data-country-code=\"BJ\" >Benin<\/option><option value=\"Bermuda\" data-country-code=\"BM\" >Bermuda<\/option><option value=\"Bhutan\" data-country-code=\"BT\" >Bhutan<\/option><option value=\"Bolivia\" data-country-code=\"BO\" >Bolivia<\/option><option value=\"Bosnia and Herzegovina\" data-country-code=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"Botswana\" data-country-code=\"BW\" >Botswana<\/option><option value=\"Bouvet Island\" data-country-code=\"BV\" >Bouvet Island<\/option><option value=\"Brazil\" data-country-code=\"BR\" >Brazil<\/option><option value=\"British Indian Ocean Territory\" data-country-code=\"IO\" >British Indian Ocean Territory<\/option><option value=\"British Virgin Islands\" data-country-code=\"VG\" >British Virgin Islands<\/option><option value=\"Brunei\" data-country-code=\"BN\" >Brunei<\/option><option value=\"Bulgaria\" data-country-code=\"BG\" >Bulgaria<\/option><option value=\"Burkina Faso\" data-country-code=\"BF\" >Burkina Faso<\/option><option value=\"Burundi\" data-country-code=\"BI\" >Burundi<\/option><option value=\"Cabo Verde\" data-country-code=\"CV\" >Cabo Verde<\/option><option value=\"Cambodia\" data-country-code=\"KH\" >Cambodia<\/option><option value=\"Cameroon\" data-country-code=\"CM\" >Cameroon<\/option><option value=\"Canada\" data-country-code=\"CA\" selected=\"selected\">Canada<\/option><option value=\"Caribbean Netherlands\" data-country-code=\"BQ\" >Caribbean Netherlands<\/option><option value=\"Cayman Islands\" data-country-code=\"KY\" >Cayman Islands<\/option><option value=\"Central African Republic\" data-country-code=\"CF\" >Central African Republic<\/option><option value=\"Chad\" data-country-code=\"TD\" >Chad<\/option><option value=\"Chile\" data-country-code=\"CL\" >Chile<\/option><option value=\"China\" data-country-code=\"CN\" >China<\/option><option value=\"Christmas Island\" data-country-code=\"CX\" >Christmas Island<\/option><option value=\"Cocos Islands\" data-country-code=\"CC\" >Cocos Islands<\/option><option value=\"Colombia\" data-country-code=\"CO\" >Colombia<\/option><option value=\"Comoros\" data-country-code=\"KM\" >Comoros<\/option><option value=\"Congo, Democratic Republic of the\" data-country-code=\"CD\" >Congo, Democratic Republic of the<\/option><option value=\"Congo, Republic of the\" data-country-code=\"CG\" >Congo, Republic of the<\/option><option value=\"Cook Islands\" data-country-code=\"CK\" >Cook Islands<\/option><option value=\"Costa Rica\" data-country-code=\"CR\" >Costa Rica<\/option><option value=\"Croatia\" data-country-code=\"HR\" >Croatia<\/option><option value=\"Cuba\" data-country-code=\"CU\" >Cuba<\/option><option value=\"Cura\u00e7ao\" data-country-code=\"CW\" >Cura\u00e7ao<\/option><option value=\"Cyprus\" data-country-code=\"CY\" >Cyprus<\/option><option value=\"Czechia\" data-country-code=\"CZ\" >Czechia<\/option><option value=\"C\u00f4te d&#039;Ivoire\" data-country-code=\"CI\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"Denmark\" data-country-code=\"DK\" >Denmark<\/option><option value=\"Djibouti\" data-country-code=\"DJ\" >Djibouti<\/option><option value=\"Dominica\" data-country-code=\"DM\" >Dominica<\/option><option value=\"Dominican Republic\" data-country-code=\"DO\" >Dominican Republic<\/option><option value=\"Ecuador\" data-country-code=\"EC\" >Ecuador<\/option><option value=\"Egypt\" data-country-code=\"EG\" >Egypt<\/option><option value=\"El Salvador\" data-country-code=\"SV\" >El Salvador<\/option><option value=\"Equatorial Guinea\" data-country-code=\"GQ\" >Equatorial Guinea<\/option><option value=\"Eritrea\" data-country-code=\"ER\" >Eritrea<\/option><option value=\"Estonia\" data-country-code=\"EE\" >Estonia<\/option><option value=\"Eswatini\" data-country-code=\"SZ\" >Eswatini<\/option><option value=\"Ethiopia\" data-country-code=\"ET\" >Ethiopia<\/option><option value=\"Falkland Islands\" data-country-code=\"FK\" >Falkland Islands<\/option><option value=\"Faroe Islands\" data-country-code=\"FO\" >Faroe Islands<\/option><option value=\"Fiji\" data-country-code=\"FJ\" >Fiji<\/option><option value=\"Finland\" data-country-code=\"FI\" >Finland<\/option><option value=\"France\" data-country-code=\"FR\" >France<\/option><option value=\"French Guiana\" data-country-code=\"GF\" >French Guiana<\/option><option value=\"French Polynesia\" data-country-code=\"PF\" >French Polynesia<\/option><option value=\"French South Territories\" data-country-code=\"TF\" >French South Territories<\/option><option value=\"Gabon\" data-country-code=\"GA\" >Gabon<\/option><option value=\"Gambia\" data-country-code=\"GM\" >Gambia<\/option><option value=\"Georgia\" data-country-code=\"GE\" >Georgia<\/option><option value=\"Germany\" data-country-code=\"DE\" >Germany<\/option><option value=\"Ghana\" data-country-code=\"GH\" >Ghana<\/option><option value=\"Gibraltar\" data-country-code=\"GI\" >Gibraltar<\/option><option value=\"Greece\" data-country-code=\"GR\" >Greece<\/option><option value=\"Greenland\" data-country-code=\"GL\" >Greenland<\/option><option value=\"Grenada\" data-country-code=\"GD\" >Grenada<\/option><option value=\"Guadeloupe\" data-country-code=\"GP\" >Guadeloupe<\/option><option value=\"Guam\" data-country-code=\"GU\" >Guam<\/option><option value=\"Guatemala\" data-country-code=\"GT\" >Guatemala<\/option><option value=\"Guernsey\" data-country-code=\"GG\" >Guernsey<\/option><option value=\"Guinea\" data-country-code=\"GN\" >Guinea<\/option><option value=\"Guinea-Bissau\" data-country-code=\"GW\" >Guinea-Bissau<\/option><option value=\"Guyana\" data-country-code=\"GY\" >Guyana<\/option><option value=\"Haiti\" data-country-code=\"HT\" >Haiti<\/option><option value=\"Heard Island And Mcdonald Island\" data-country-code=\"HM\" >Heard Island And Mcdonald Island<\/option><option value=\"Honduras\" data-country-code=\"HN\" >Honduras<\/option><option value=\"Hong Kong SAR China\" data-country-code=\"HK\" >Hong Kong SAR China<\/option><option value=\"Hungary\" data-country-code=\"HU\" >Hungary<\/option><option value=\"Iceland\" data-country-code=\"IS\" >Iceland<\/option><option value=\"India\" data-country-code=\"IN\" >India<\/option><option value=\"Indonesia\" data-country-code=\"ID\" >Indonesia<\/option><option value=\"Iran\" data-country-code=\"IR\" >Iran<\/option><option value=\"Iraq\" data-country-code=\"IQ\" >Iraq<\/option><option value=\"Ireland\" data-country-code=\"IE\" >Ireland<\/option><option value=\"Isle of Man\" data-country-code=\"IM\" >Isle of Man<\/option><option value=\"Israel\" data-country-code=\"IL\" >Israel<\/option><option value=\"Italy\" data-country-code=\"IT\" >Italy<\/option><option value=\"Jamaica\" data-country-code=\"JM\" >Jamaica<\/option><option value=\"Japan\" data-country-code=\"JP\" >Japan<\/option><option value=\"Jersey\" data-country-code=\"JE\" >Jersey<\/option><option value=\"Jordan\" data-country-code=\"JO\" >Jordan<\/option><option value=\"Kazakhstan\" data-country-code=\"KZ\" >Kazakhstan<\/option><option value=\"Kenya\" data-country-code=\"KE\" >Kenya<\/option><option value=\"Kiribati\" data-country-code=\"KI\" >Kiribati<\/option><option value=\"Kosovo\" data-country-code=\"XK\" >Kosovo<\/option><option value=\"Kuwait\" data-country-code=\"KW\" >Kuwait<\/option><option value=\"Kyrgyzstan\" data-country-code=\"KG\" >Kyrgyzstan<\/option><option value=\"Lao People&#039;s Democratic Republic\" data-country-code=\"LA\" >Lao People&#039;s Democratic Republic<\/option><option value=\"Latvia\" data-country-code=\"LV\" >Latvia<\/option><option value=\"Lebanon\" data-country-code=\"LB\" >Lebanon<\/option><option value=\"Lesotho\" data-country-code=\"LS\" >Lesotho<\/option><option value=\"Liberia\" data-country-code=\"LR\" >Liberia<\/option><option value=\"Libya\" data-country-code=\"LY\" >Libya<\/option><option value=\"Liechtenstein\" data-country-code=\"LI\" >Liechtenstein<\/option><option value=\"Lithuania\" data-country-code=\"LT\" >Lithuania<\/option><option value=\"Luxembourg\" data-country-code=\"LU\" >Luxembourg<\/option><option value=\"Macao SAR China\" data-country-code=\"MO\" >Macao SAR China<\/option><option value=\"Madagascar\" data-country-code=\"MG\" >Madagascar<\/option><option value=\"Malawi\" data-country-code=\"MW\" >Malawi<\/option><option value=\"Malaysia\" data-country-code=\"MY\" >Malaysia<\/option><option value=\"Maldives\" data-country-code=\"MV\" >Maldives<\/option><option value=\"Mali\" data-country-code=\"ML\" >Mali<\/option><option value=\"Malta\" data-country-code=\"MT\" >Malta<\/option><option value=\"Marshall Islands\" data-country-code=\"MH\" >Marshall Islands<\/option><option value=\"Martinique\" data-country-code=\"MQ\" >Martinique<\/option><option value=\"Mauritania\" data-country-code=\"MR\" >Mauritania<\/option><option value=\"Mauritius\" data-country-code=\"MU\" >Mauritius<\/option><option value=\"Mayotte\" data-country-code=\"YT\" >Mayotte<\/option><option value=\"Mexico\" data-country-code=\"MX\" >Mexico<\/option><option value=\"Micronesia\" data-country-code=\"FM\" >Micronesia<\/option><option value=\"Moldova\" data-country-code=\"MD\" >Moldova<\/option><option value=\"Monaco\" data-country-code=\"MC\" >Monaco<\/option><option value=\"Mongolia\" data-country-code=\"MN\" >Mongolia<\/option><option value=\"Montenegro\" data-country-code=\"ME\" >Montenegro<\/option><option value=\"Montserrat\" data-country-code=\"MS\" >Montserrat<\/option><option value=\"Morocco\" data-country-code=\"MA\" >Morocco<\/option><option value=\"Mozambique\" data-country-code=\"MZ\" >Mozambique<\/option><option value=\"Myanmar\" data-country-code=\"MM\" >Myanmar<\/option><option value=\"Namibia\" data-country-code=\"NA\" >Namibia<\/option><option value=\"Nauru\" data-country-code=\"NR\" >Nauru<\/option><option value=\"Nepal\" data-country-code=\"NP\" >Nepal<\/option><option value=\"Netherlands\" data-country-code=\"NL\" >Netherlands<\/option><option value=\"New Caledonia\" data-country-code=\"NC\" >New Caledonia<\/option><option value=\"New Zealand\" data-country-code=\"NZ\" >New Zealand<\/option><option value=\"Nicaragua\" data-country-code=\"NI\" >Nicaragua<\/option><option value=\"Niger\" data-country-code=\"NE\" >Niger<\/option><option value=\"Nigeria\" data-country-code=\"NG\" >Nigeria<\/option><option value=\"Niue\" data-country-code=\"NU\" >Niue<\/option><option value=\"Norfolk Island\" data-country-code=\"NF\" >Norfolk Island<\/option><option value=\"North Korea\" data-country-code=\"KP\" >North Korea<\/option><option value=\"North Macedonia\" data-country-code=\"MK\" >North Macedonia<\/option><option value=\"Northern Mariana Islands\" data-country-code=\"MP\" >Northern Mariana Islands<\/option><option value=\"Norway\" data-country-code=\"NO\" >Norway<\/option><option value=\"Oman\" data-country-code=\"OM\" >Oman<\/option><option value=\"Pakistan\" data-country-code=\"PK\" >Pakistan<\/option><option value=\"Palau\" data-country-code=\"PW\" >Palau<\/option><option value=\"Palestinian Territories\" data-country-code=\"PS\" >Palestinian Territories<\/option><option value=\"Panama\" data-country-code=\"PA\" >Panama<\/option><option value=\"Papua New Guinea\" data-country-code=\"PG\" >Papua New Guinea<\/option><option value=\"Paraguay\" data-country-code=\"PY\" >Paraguay<\/option><option value=\"Peru\" data-country-code=\"PE\" >Peru<\/option><option value=\"Philippines\" data-country-code=\"PH\" >Philippines<\/option><option value=\"Pitcairn Islands\" data-country-code=\"PN\" >Pitcairn Islands<\/option><option value=\"Poland\" data-country-code=\"PL\" >Poland<\/option><option value=\"Portugal\" data-country-code=\"PT\" >Portugal<\/option><option value=\"Puerto Rico\" data-country-code=\"PR\" >Puerto Rico<\/option><option value=\"Qatar\" data-country-code=\"QA\" >Qatar<\/option><option value=\"Romania\" data-country-code=\"RO\" >Romania<\/option><option value=\"Russia\" data-country-code=\"RU\" >Russia<\/option><option value=\"Rwanda\" data-country-code=\"RW\" >Rwanda<\/option><option value=\"R\u00e9union\" data-country-code=\"RE\" >R\u00e9union<\/option><option value=\"Saint Helena\" data-country-code=\"SH\" >Saint Helena<\/option><option value=\"Saint Kitts and Nevis\" data-country-code=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\" data-country-code=\"LC\" >Saint Lucia<\/option><option value=\"Saint Vincent and the Grenadines\" data-country-code=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"Samoa\" data-country-code=\"WS\" >Samoa<\/option><option value=\"San Marino\" data-country-code=\"SM\" >San Marino<\/option><option value=\"Saudi Arabia\" data-country-code=\"SA\" >Saudi Arabia<\/option><option value=\"Senegal\" data-country-code=\"SN\" >Senegal<\/option><option value=\"Serbia\" data-country-code=\"RS\" >Serbia<\/option><option value=\"Seychelles\" data-country-code=\"SC\" >Seychelles<\/option><option value=\"Sierra Leone\" data-country-code=\"SL\" >Sierra Leone<\/option><option value=\"Singapore\" data-country-code=\"SG\" >Singapore<\/option><option value=\"Sint Maarten\" data-country-code=\"SX\" >Sint Maarten<\/option><option value=\"Slovakia\" data-country-code=\"SK\" >Slovakia<\/option><option value=\"Slovenia\" data-country-code=\"SI\" >Slovenia<\/option><option value=\"Solomon Islands\" data-country-code=\"SB\" >Solomon Islands<\/option><option value=\"Somalia\" data-country-code=\"SO\" >Somalia<\/option><option value=\"South Africa\" data-country-code=\"ZA\" >South Africa<\/option><option value=\"South Georgia and South Sandwich\" data-country-code=\"GS\" >South Georgia and South Sandwich<\/option><option value=\"South Korea\" data-country-code=\"KR\" >South Korea<\/option><option value=\"South Sudan\" data-country-code=\"SS\" >South Sudan<\/option><option value=\"Spain\" data-country-code=\"ES\" >Spain<\/option><option value=\"Sri Lanka\" data-country-code=\"LK\" >Sri Lanka<\/option><option value=\"St. Barth\u00e9lemy\" data-country-code=\"BL\" >St. Barth\u00e9lemy<\/option><option value=\"St. Martin\" data-country-code=\"MF\" >St. Martin<\/option><option value=\"St. Pierre &amp; Miquelon\" data-country-code=\"PM\" >St. Pierre &amp; Miquelon<\/option><option value=\"Sudan\" data-country-code=\"SD\" >Sudan<\/option><option value=\"Suriname\" data-country-code=\"SR\" >Suriname<\/option><option value=\"Svalbard and Jan Mayen\" data-country-code=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"Sweden\" data-country-code=\"SE\" >Sweden<\/option><option value=\"Switzerland\" data-country-code=\"CH\" >Switzerland<\/option><option value=\"Syria\" data-country-code=\"SY\" >Syria<\/option><option value=\"S\u00e3o Tom\u00e9 &amp; Pr\u00edncipe\" data-country-code=\"ST\" >S\u00e3o Tom\u00e9 &amp; Pr\u00edncipe<\/option><option value=\"Taiwan\" data-country-code=\"TW\" >Taiwan<\/option><option value=\"Tajikistan\" data-country-code=\"TJ\" >Tajikistan<\/option><option value=\"Tanzania\" data-country-code=\"TZ\" >Tanzania<\/option><option value=\"Thailand\" data-country-code=\"TH\" >Thailand<\/option><option value=\"Timor-Leste\" data-country-code=\"TL\" >Timor-Leste<\/option><option value=\"Togo\" data-country-code=\"TG\" >Togo<\/option><option value=\"Tokelau\" data-country-code=\"TK\" >Tokelau<\/option><option value=\"Tonga\" data-country-code=\"TO\" >Tonga<\/option><option value=\"Trinidad &amp; Tobago\" data-country-code=\"TT\" >Trinidad &amp; Tobago<\/option><option value=\"Tunisia\" data-country-code=\"TN\" >Tunisia<\/option><option value=\"Turkey\" data-country-code=\"TR\" >Turkey<\/option><option value=\"Turkmenistan\" data-country-code=\"TM\" >Turkmenistan<\/option><option value=\"Turks &amp; Caicos Islands\" data-country-code=\"TC\" >Turks &amp; Caicos Islands<\/option><option value=\"Tuvalu\" data-country-code=\"TV\" >Tuvalu<\/option><option value=\"U.S. Virgin Islands\" data-country-code=\"VI\" >U.S. Virgin Islands<\/option><option value=\"US Minor Outlying Islands\" data-country-code=\"UM\" >US Minor Outlying Islands<\/option><option value=\"Uganda\" data-country-code=\"UG\" >Uganda<\/option><option value=\"Ukraine\" data-country-code=\"UA\" >Ukraine<\/option><option value=\"United Arab Emirates\" data-country-code=\"AE\" >United Arab Emirates<\/option><option value=\"United Kingdom\" data-country-code=\"GB\" >United Kingdom<\/option><option value=\"United States of America (USA)\" data-country-code=\"US\" >United States of America (USA)<\/option><option value=\"Uruguay\" data-country-code=\"UY\" >Uruguay<\/option><option value=\"Uzbekistan\" data-country-code=\"UZ\" >Uzbekistan<\/option><option value=\"Vanuatu\" data-country-code=\"VU\" >Vanuatu<\/option><option value=\"Vatican City\" data-country-code=\"VA\" >Vatican City<\/option><option value=\"Venezuela\" data-country-code=\"VE\" >Venezuela<\/option><option value=\"Vietnam\" data-country-code=\"VN\" >Vietnam<\/option><option value=\"Wallis And Futuna Islands\" data-country-code=\"WF\" >Wallis And Futuna Islands<\/option><option value=\"Western Sahara\" data-country-code=\"EH\" >Western Sahara<\/option><option value=\"Yemen\" data-country-code=\"YE\" >Yemen<\/option><option value=\"Zambia\" data-country-code=\"ZM\" >Zambia<\/option><option value=\"Zimbabwe\" data-country-code=\"ZW\" >Zimbabwe<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div id=\"group-2\" class=\"forminator-field-group forminator-col forminator-col-6 \"><label class=\"forminator-label forminator-repeater-label\">Dealer Information<\/label><span class=\"forminator-description forminator-repeater-description\">Only necessary if different than the Customer information<\/span><div class=\"forminator-all-group-copies forminator-repeater-field\"><div class=\"forminator-grouped-fields\" data-options=\"{&quot;is_repeater&quot;:false,&quot;min_type&quot;:&quot;custom&quot;,&quot;max_type&quot;:&quot;custom&quot;,&quot;min&quot;:1,&quot;max&quot;:9223372036854775807,&quot;add_text&quot;:&quot;Add item&quot;,&quot;remove_text&quot;:&quot;Remove item&quot;,&quot;action_element_type&quot;:&quot;button&quot;}\"><div class=\"forminator-row\"><div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-2_6a6d38243145c\" id=\"forminator-field-name-2_6a6d38243145c-label\" class=\"forminator-label\">Contact Name<\/label><input type=\"text\" name=\"name-2\" value=\"\" placeholder=\"\" id=\"forminator-field-name-2_6a6d38243145c\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_6a6d38243145c\" id=\"forminator-field-text-2_6a6d38243145c-label\" class=\"forminator-label\">Company Name<\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_6a6d38243145c\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"phone-2\" class=\"forminator-field-phone forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-2_6a6d38243145c\" id=\"forminator-field-phone-2_6a6d38243145c-label\" class=\"forminator-label\">Phone Number<\/label><input type=\"text\" name=\"phone-2\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-2_6a6d38243145c\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-2\" class=\"forminator-field-address forminator-col forminator-col-12 \"><div class=\"forminator-row\"><div id=\"address-2-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-street_address_6a6d38243145c\" id=\"forminator-field-address-2-street_address_6a6d38243145c-label\" class=\"forminator-label\">Street Address<\/label><input type=\"text\" name=\"address-2-street_address\" placeholder=\"\" id=\"forminator-field-address-2-street_address_6a6d38243145c\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-2-address_line\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-address_line_6a6d38243145c\" id=\"forminator-field-address-2-address_line_6a6d38243145c-label\" class=\"forminator-label\">Apartment, suite, etc<\/label><input type=\"text\" name=\"address-2-address_line\" placeholder=\"\" id=\"forminator-field-address-2-address_line_6a6d38243145c\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line2\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"address-2-city\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-city_6a6d38243145c\" id=\"forminator-field-address-2-city_6a6d38243145c-label\" class=\"forminator-label\">City<\/label><input type=\"text\" name=\"address-2-city\" placeholder=\"\" id=\"forminator-field-address-2-city_6a6d38243145c\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-level2\" value=\"\" \/><\/div><\/div><div id=\"address-2-state\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-state_6a6d38243145c\" id=\"forminator-field-address-2-state_6a6d38243145c-label\" class=\"forminator-label\">Province<\/label><input type=\"text\" name=\"address-2-state\" placeholder=\"\" id=\"forminator-field-address-2-state_6a6d38243145c\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-level1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"address-2-zip\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-zip_6a6d38243145c\" id=\"forminator-field-address-2-zip_6a6d38243145c-label\" class=\"forminator-label\">Postal Code<\/label><input type=\"text\" name=\"address-2-zip\" placeholder=\"\" id=\"forminator-field-address-2-zip_6a6d38243145c\" class=\"forminator-input\" autocomplete=\"postal-code\" value=\"\" \/><\/div><\/div><div id=\"address-2-country\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-2769__field--address-2-country_6a6d38243145c\" id=\"forminator-field-2769__field--address-2-country_6a6d38243145c-label\" class=\"forminator-label\">Country<\/label><select name=\"address-2-country\" id=\"forminator-field-2769__field--address-2-country_6a6d38243145c\" class=\"forminator-select2\" data-search=\"true\" data-placeholder=\"Select country\" autocomplete=\"country-name\" data-default-value=\"Canada\"><option value=\"\" data-country-code=\"\" selected=\"selected\"><\/option><option value=\"Afghanistan\" data-country-code=\"AF\" >Afghanistan<\/option><option value=\"Albania\" data-country-code=\"AL\" >Albania<\/option><option value=\"Algeria\" data-country-code=\"DZ\" >Algeria<\/option><option value=\"American Samoa\" data-country-code=\"AS\" >American Samoa<\/option><option value=\"Andorra\" data-country-code=\"AD\" >Andorra<\/option><option value=\"Angola\" data-country-code=\"AO\" >Angola<\/option><option value=\"Anguilla\" data-country-code=\"AI\" >Anguilla<\/option><option value=\"Antarctica\" data-country-code=\"AQ\" >Antarctica<\/option><option value=\"Antigua &amp; Barbuda\" data-country-code=\"AG\" >Antigua &amp; Barbuda<\/option><option value=\"Argentina\" data-country-code=\"AR\" >Argentina<\/option><option value=\"Armenia\" data-country-code=\"AM\" >Armenia<\/option><option value=\"Aruba\" data-country-code=\"AW\" >Aruba<\/option><option value=\"Ascension Island\" data-country-code=\"AC\" >Ascension Island<\/option><option value=\"Australia\" data-country-code=\"AU\" >Australia<\/option><option value=\"Austria\" data-country-code=\"AT\" >Austria<\/option><option value=\"Azerbaijan\" data-country-code=\"AZ\" >Azerbaijan<\/option><option value=\"Bahamas\" data-country-code=\"BS\" >Bahamas<\/option><option value=\"Bahrain\" data-country-code=\"BH\" >Bahrain<\/option><option value=\"Bangladesh\" data-country-code=\"BD\" >Bangladesh<\/option><option value=\"Barbados\" data-country-code=\"BB\" >Barbados<\/option><option value=\"Belarus\" data-country-code=\"BY\" >Belarus<\/option><option value=\"Belgium\" data-country-code=\"BE\" >Belgium<\/option><option value=\"Belize\" data-country-code=\"BZ\" >Belize<\/option><option value=\"Benin\" data-country-code=\"BJ\" >Benin<\/option><option value=\"Bermuda\" data-country-code=\"BM\" >Bermuda<\/option><option value=\"Bhutan\" data-country-code=\"BT\" >Bhutan<\/option><option value=\"Bolivia\" data-country-code=\"BO\" >Bolivia<\/option><option value=\"Bosnia and Herzegovina\" data-country-code=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"Botswana\" data-country-code=\"BW\" >Botswana<\/option><option value=\"Bouvet Island\" data-country-code=\"BV\" >Bouvet Island<\/option><option value=\"Brazil\" data-country-code=\"BR\" >Brazil<\/option><option value=\"British Indian Ocean Territory\" data-country-code=\"IO\" >British Indian Ocean Territory<\/option><option value=\"British Virgin Islands\" data-country-code=\"VG\" >British Virgin Islands<\/option><option value=\"Brunei\" data-country-code=\"BN\" >Brunei<\/option><option value=\"Bulgaria\" data-country-code=\"BG\" >Bulgaria<\/option><option value=\"Burkina Faso\" data-country-code=\"BF\" >Burkina Faso<\/option><option value=\"Burundi\" data-country-code=\"BI\" >Burundi<\/option><option value=\"Cabo Verde\" data-country-code=\"CV\" >Cabo Verde<\/option><option value=\"Cambodia\" data-country-code=\"KH\" >Cambodia<\/option><option value=\"Cameroon\" data-country-code=\"CM\" >Cameroon<\/option><option value=\"Canada\" data-country-code=\"CA\" selected=\"selected\">Canada<\/option><option value=\"Caribbean Netherlands\" data-country-code=\"BQ\" >Caribbean Netherlands<\/option><option value=\"Cayman Islands\" data-country-code=\"KY\" >Cayman Islands<\/option><option value=\"Central African Republic\" data-country-code=\"CF\" >Central African Republic<\/option><option value=\"Chad\" data-country-code=\"TD\" >Chad<\/option><option value=\"Chile\" data-country-code=\"CL\" >Chile<\/option><option value=\"China\" data-country-code=\"CN\" >China<\/option><option value=\"Christmas Island\" data-country-code=\"CX\" >Christmas Island<\/option><option value=\"Cocos Islands\" data-country-code=\"CC\" >Cocos Islands<\/option><option value=\"Colombia\" data-country-code=\"CO\" >Colombia<\/option><option value=\"Comoros\" data-country-code=\"KM\" >Comoros<\/option><option value=\"Congo, Democratic Republic of the\" data-country-code=\"CD\" >Congo, Democratic Republic of the<\/option><option value=\"Congo, Republic of the\" data-country-code=\"CG\" >Congo, Republic of the<\/option><option value=\"Cook Islands\" data-country-code=\"CK\" >Cook Islands<\/option><option value=\"Costa Rica\" data-country-code=\"CR\" >Costa Rica<\/option><option value=\"Croatia\" data-country-code=\"HR\" >Croatia<\/option><option value=\"Cuba\" data-country-code=\"CU\" >Cuba<\/option><option value=\"Cura\u00e7ao\" data-country-code=\"CW\" >Cura\u00e7ao<\/option><option value=\"Cyprus\" data-country-code=\"CY\" >Cyprus<\/option><option value=\"Czechia\" data-country-code=\"CZ\" >Czechia<\/option><option value=\"C\u00f4te d&#039;Ivoire\" data-country-code=\"CI\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"Denmark\" data-country-code=\"DK\" >Denmark<\/option><option value=\"Djibouti\" data-country-code=\"DJ\" >Djibouti<\/option><option value=\"Dominica\" data-country-code=\"DM\" >Dominica<\/option><option value=\"Dominican Republic\" data-country-code=\"DO\" >Dominican Republic<\/option><option value=\"Ecuador\" data-country-code=\"EC\" >Ecuador<\/option><option value=\"Egypt\" data-country-code=\"EG\" >Egypt<\/option><option value=\"El Salvador\" data-country-code=\"SV\" >El Salvador<\/option><option value=\"Equatorial Guinea\" data-country-code=\"GQ\" >Equatorial Guinea<\/option><option value=\"Eritrea\" data-country-code=\"ER\" >Eritrea<\/option><option value=\"Estonia\" data-country-code=\"EE\" >Estonia<\/option><option value=\"Eswatini\" data-country-code=\"SZ\" >Eswatini<\/option><option value=\"Ethiopia\" data-country-code=\"ET\" >Ethiopia<\/option><option value=\"Falkland Islands\" data-country-code=\"FK\" >Falkland Islands<\/option><option value=\"Faroe Islands\" data-country-code=\"FO\" >Faroe Islands<\/option><option value=\"Fiji\" data-country-code=\"FJ\" >Fiji<\/option><option value=\"Finland\" data-country-code=\"FI\" >Finland<\/option><option value=\"France\" data-country-code=\"FR\" >France<\/option><option value=\"French Guiana\" data-country-code=\"GF\" >French Guiana<\/option><option value=\"French Polynesia\" data-country-code=\"PF\" >French Polynesia<\/option><option value=\"French South Territories\" data-country-code=\"TF\" >French South Territories<\/option><option value=\"Gabon\" data-country-code=\"GA\" >Gabon<\/option><option value=\"Gambia\" data-country-code=\"GM\" >Gambia<\/option><option value=\"Georgia\" data-country-code=\"GE\" >Georgia<\/option><option value=\"Germany\" data-country-code=\"DE\" >Germany<\/option><option value=\"Ghana\" data-country-code=\"GH\" >Ghana<\/option><option value=\"Gibraltar\" data-country-code=\"GI\" >Gibraltar<\/option><option value=\"Greece\" data-country-code=\"GR\" >Greece<\/option><option value=\"Greenland\" data-country-code=\"GL\" >Greenland<\/option><option value=\"Grenada\" data-country-code=\"GD\" >Grenada<\/option><option value=\"Guadeloupe\" data-country-code=\"GP\" >Guadeloupe<\/option><option value=\"Guam\" data-country-code=\"GU\" >Guam<\/option><option value=\"Guatemala\" data-country-code=\"GT\" >Guatemala<\/option><option value=\"Guernsey\" data-country-code=\"GG\" >Guernsey<\/option><option value=\"Guinea\" data-country-code=\"GN\" >Guinea<\/option><option value=\"Guinea-Bissau\" data-country-code=\"GW\" >Guinea-Bissau<\/option><option value=\"Guyana\" data-country-code=\"GY\" >Guyana<\/option><option value=\"Haiti\" data-country-code=\"HT\" >Haiti<\/option><option value=\"Heard Island And Mcdonald Island\" data-country-code=\"HM\" >Heard Island And Mcdonald Island<\/option><option value=\"Honduras\" data-country-code=\"HN\" >Honduras<\/option><option value=\"Hong Kong SAR China\" data-country-code=\"HK\" >Hong Kong SAR China<\/option><option value=\"Hungary\" data-country-code=\"HU\" >Hungary<\/option><option value=\"Iceland\" data-country-code=\"IS\" >Iceland<\/option><option value=\"India\" data-country-code=\"IN\" >India<\/option><option value=\"Indonesia\" data-country-code=\"ID\" >Indonesia<\/option><option value=\"Iran\" data-country-code=\"IR\" >Iran<\/option><option value=\"Iraq\" data-country-code=\"IQ\" >Iraq<\/option><option value=\"Ireland\" data-country-code=\"IE\" >Ireland<\/option><option value=\"Isle of Man\" data-country-code=\"IM\" >Isle of Man<\/option><option value=\"Israel\" data-country-code=\"IL\" >Israel<\/option><option value=\"Italy\" data-country-code=\"IT\" >Italy<\/option><option value=\"Jamaica\" data-country-code=\"JM\" >Jamaica<\/option><option value=\"Japan\" data-country-code=\"JP\" >Japan<\/option><option value=\"Jersey\" data-country-code=\"JE\" >Jersey<\/option><option value=\"Jordan\" data-country-code=\"JO\" >Jordan<\/option><option value=\"Kazakhstan\" data-country-code=\"KZ\" >Kazakhstan<\/option><option value=\"Kenya\" data-country-code=\"KE\" >Kenya<\/option><option value=\"Kiribati\" data-country-code=\"KI\" >Kiribati<\/option><option value=\"Kosovo\" data-country-code=\"XK\" >Kosovo<\/option><option value=\"Kuwait\" data-country-code=\"KW\" >Kuwait<\/option><option value=\"Kyrgyzstan\" data-country-code=\"KG\" >Kyrgyzstan<\/option><option value=\"Lao People&#039;s Democratic Republic\" data-country-code=\"LA\" >Lao People&#039;s Democratic Republic<\/option><option value=\"Latvia\" data-country-code=\"LV\" >Latvia<\/option><option value=\"Lebanon\" data-country-code=\"LB\" >Lebanon<\/option><option value=\"Lesotho\" data-country-code=\"LS\" >Lesotho<\/option><option value=\"Liberia\" data-country-code=\"LR\" >Liberia<\/option><option value=\"Libya\" data-country-code=\"LY\" >Libya<\/option><option value=\"Liechtenstein\" data-country-code=\"LI\" >Liechtenstein<\/option><option value=\"Lithuania\" data-country-code=\"LT\" >Lithuania<\/option><option value=\"Luxembourg\" data-country-code=\"LU\" >Luxembourg<\/option><option value=\"Macao SAR China\" data-country-code=\"MO\" >Macao SAR China<\/option><option value=\"Madagascar\" data-country-code=\"MG\" >Madagascar<\/option><option value=\"Malawi\" data-country-code=\"MW\" >Malawi<\/option><option value=\"Malaysia\" data-country-code=\"MY\" >Malaysia<\/option><option value=\"Maldives\" data-country-code=\"MV\" >Maldives<\/option><option value=\"Mali\" data-country-code=\"ML\" >Mali<\/option><option value=\"Malta\" data-country-code=\"MT\" >Malta<\/option><option value=\"Marshall Islands\" data-country-code=\"MH\" >Marshall Islands<\/option><option value=\"Martinique\" data-country-code=\"MQ\" >Martinique<\/option><option value=\"Mauritania\" data-country-code=\"MR\" >Mauritania<\/option><option value=\"Mauritius\" data-country-code=\"MU\" >Mauritius<\/option><option value=\"Mayotte\" data-country-code=\"YT\" >Mayotte<\/option><option value=\"Mexico\" data-country-code=\"MX\" >Mexico<\/option><option value=\"Micronesia\" data-country-code=\"FM\" >Micronesia<\/option><option value=\"Moldova\" data-country-code=\"MD\" >Moldova<\/option><option value=\"Monaco\" data-country-code=\"MC\" >Monaco<\/option><option value=\"Mongolia\" data-country-code=\"MN\" >Mongolia<\/option><option value=\"Montenegro\" data-country-code=\"ME\" >Montenegro<\/option><option value=\"Montserrat\" data-country-code=\"MS\" >Montserrat<\/option><option value=\"Morocco\" data-country-code=\"MA\" >Morocco<\/option><option value=\"Mozambique\" data-country-code=\"MZ\" >Mozambique<\/option><option value=\"Myanmar\" data-country-code=\"MM\" >Myanmar<\/option><option value=\"Namibia\" data-country-code=\"NA\" >Namibia<\/option><option value=\"Nauru\" data-country-code=\"NR\" >Nauru<\/option><option value=\"Nepal\" data-country-code=\"NP\" >Nepal<\/option><option value=\"Netherlands\" data-country-code=\"NL\" >Netherlands<\/option><option value=\"New Caledonia\" data-country-code=\"NC\" >New Caledonia<\/option><option value=\"New Zealand\" data-country-code=\"NZ\" >New Zealand<\/option><option value=\"Nicaragua\" data-country-code=\"NI\" >Nicaragua<\/option><option value=\"Niger\" data-country-code=\"NE\" >Niger<\/option><option value=\"Nigeria\" data-country-code=\"NG\" >Nigeria<\/option><option value=\"Niue\" data-country-code=\"NU\" >Niue<\/option><option value=\"Norfolk Island\" data-country-code=\"NF\" >Norfolk Island<\/option><option value=\"North Korea\" data-country-code=\"KP\" >North Korea<\/option><option value=\"North Macedonia\" data-country-code=\"MK\" >North Macedonia<\/option><option value=\"Northern Mariana Islands\" data-country-code=\"MP\" >Northern Mariana Islands<\/option><option value=\"Norway\" data-country-code=\"NO\" >Norway<\/option><option value=\"Oman\" data-country-code=\"OM\" >Oman<\/option><option value=\"Pakistan\" data-country-code=\"PK\" >Pakistan<\/option><option value=\"Palau\" data-country-code=\"PW\" >Palau<\/option><option value=\"Palestinian Territories\" data-country-code=\"PS\" >Palestinian Territories<\/option><option value=\"Panama\" data-country-code=\"PA\" >Panama<\/option><option value=\"Papua New Guinea\" data-country-code=\"PG\" >Papua New Guinea<\/option><option value=\"Paraguay\" data-country-code=\"PY\" >Paraguay<\/option><option value=\"Peru\" data-country-code=\"PE\" >Peru<\/option><option value=\"Philippines\" data-country-code=\"PH\" >Philippines<\/option><option value=\"Pitcairn Islands\" data-country-code=\"PN\" >Pitcairn Islands<\/option><option value=\"Poland\" data-country-code=\"PL\" >Poland<\/option><option value=\"Portugal\" data-country-code=\"PT\" >Portugal<\/option><option value=\"Puerto Rico\" data-country-code=\"PR\" >Puerto Rico<\/option><option value=\"Qatar\" data-country-code=\"QA\" >Qatar<\/option><option value=\"Romania\" data-country-code=\"RO\" >Romania<\/option><option value=\"Russia\" data-country-code=\"RU\" >Russia<\/option><option value=\"Rwanda\" data-country-code=\"RW\" >Rwanda<\/option><option value=\"R\u00e9union\" data-country-code=\"RE\" >R\u00e9union<\/option><option value=\"Saint Helena\" data-country-code=\"SH\" >Saint Helena<\/option><option value=\"Saint Kitts and Nevis\" data-country-code=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\" data-country-code=\"LC\" >Saint Lucia<\/option><option value=\"Saint Vincent and the Grenadines\" data-country-code=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"Samoa\" data-country-code=\"WS\" >Samoa<\/option><option value=\"San Marino\" data-country-code=\"SM\" >San Marino<\/option><option value=\"Saudi Arabia\" data-country-code=\"SA\" >Saudi Arabia<\/option><option value=\"Senegal\" data-country-code=\"SN\" >Senegal<\/option><option value=\"Serbia\" data-country-code=\"RS\" >Serbia<\/option><option value=\"Seychelles\" data-country-code=\"SC\" >Seychelles<\/option><option value=\"Sierra Leone\" data-country-code=\"SL\" >Sierra Leone<\/option><option value=\"Singapore\" data-country-code=\"SG\" >Singapore<\/option><option value=\"Sint Maarten\" data-country-code=\"SX\" >Sint Maarten<\/option><option value=\"Slovakia\" data-country-code=\"SK\" >Slovakia<\/option><option value=\"Slovenia\" data-country-code=\"SI\" >Slovenia<\/option><option value=\"Solomon Islands\" data-country-code=\"SB\" >Solomon Islands<\/option><option value=\"Somalia\" data-country-code=\"SO\" >Somalia<\/option><option value=\"South Africa\" data-country-code=\"ZA\" >South Africa<\/option><option value=\"South Georgia and South Sandwich\" data-country-code=\"GS\" >South Georgia and South Sandwich<\/option><option value=\"South Korea\" data-country-code=\"KR\" >South Korea<\/option><option value=\"South Sudan\" data-country-code=\"SS\" >South Sudan<\/option><option value=\"Spain\" data-country-code=\"ES\" >Spain<\/option><option value=\"Sri Lanka\" data-country-code=\"LK\" >Sri Lanka<\/option><option value=\"St. Barth\u00e9lemy\" data-country-code=\"BL\" >St. Barth\u00e9lemy<\/option><option value=\"St. Martin\" data-country-code=\"MF\" >St. Martin<\/option><option value=\"St. Pierre &amp; Miquelon\" data-country-code=\"PM\" >St. Pierre &amp; Miquelon<\/option><option value=\"Sudan\" data-country-code=\"SD\" >Sudan<\/option><option value=\"Suriname\" data-country-code=\"SR\" >Suriname<\/option><option value=\"Svalbard and Jan Mayen\" data-country-code=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"Sweden\" data-country-code=\"SE\" >Sweden<\/option><option value=\"Switzerland\" data-country-code=\"CH\" >Switzerland<\/option><option value=\"Syria\" data-country-code=\"SY\" >Syria<\/option><option value=\"S\u00e3o Tom\u00e9 &amp; Pr\u00edncipe\" data-country-code=\"ST\" >S\u00e3o Tom\u00e9 &amp; Pr\u00edncipe<\/option><option value=\"Taiwan\" data-country-code=\"TW\" >Taiwan<\/option><option value=\"Tajikistan\" data-country-code=\"TJ\" >Tajikistan<\/option><option value=\"Tanzania\" data-country-code=\"TZ\" >Tanzania<\/option><option value=\"Thailand\" data-country-code=\"TH\" >Thailand<\/option><option value=\"Timor-Leste\" data-country-code=\"TL\" >Timor-Leste<\/option><option value=\"Togo\" data-country-code=\"TG\" >Togo<\/option><option value=\"Tokelau\" data-country-code=\"TK\" >Tokelau<\/option><option value=\"Tonga\" data-country-code=\"TO\" >Tonga<\/option><option value=\"Trinidad &amp; Tobago\" data-country-code=\"TT\" >Trinidad &amp; Tobago<\/option><option value=\"Tunisia\" data-country-code=\"TN\" >Tunisia<\/option><option value=\"Turkey\" data-country-code=\"TR\" >Turkey<\/option><option value=\"Turkmenistan\" data-country-code=\"TM\" >Turkmenistan<\/option><option value=\"Turks &amp; Caicos Islands\" data-country-code=\"TC\" >Turks &amp; Caicos Islands<\/option><option value=\"Tuvalu\" data-country-code=\"TV\" >Tuvalu<\/option><option value=\"U.S. Virgin Islands\" data-country-code=\"VI\" >U.S. Virgin Islands<\/option><option value=\"US Minor Outlying Islands\" data-country-code=\"UM\" >US Minor Outlying Islands<\/option><option value=\"Uganda\" data-country-code=\"UG\" >Uganda<\/option><option value=\"Ukraine\" data-country-code=\"UA\" >Ukraine<\/option><option value=\"United Arab Emirates\" data-country-code=\"AE\" >United Arab Emirates<\/option><option value=\"United Kingdom\" data-country-code=\"GB\" >United Kingdom<\/option><option value=\"United States of America (USA)\" data-country-code=\"US\" >United States of America (USA)<\/option><option value=\"Uruguay\" data-country-code=\"UY\" >Uruguay<\/option><option value=\"Uzbekistan\" data-country-code=\"UZ\" >Uzbekistan<\/option><option value=\"Vanuatu\" data-country-code=\"VU\" >Vanuatu<\/option><option value=\"Vatican City\" data-country-code=\"VA\" >Vatican City<\/option><option value=\"Venezuela\" data-country-code=\"VE\" >Venezuela<\/option><option value=\"Vietnam\" data-country-code=\"VN\" >Vietnam<\/option><option value=\"Wallis And Futuna Islands\" data-country-code=\"WF\" >Wallis And Futuna Islands<\/option><option value=\"Western Sahara\" data-country-code=\"EH\" >Western Sahara<\/option><option value=\"Yemen\" data-country-code=\"YE\" >Yemen<\/option><option value=\"Zambia\" data-country-code=\"ZM\" >Zambia<\/option><option value=\"Zimbabwe\" data-country-code=\"ZW\" >Zimbabwe<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"group-3\" class=\"forminator-field-group forminator-col forminator-col-12 \"><label class=\"forminator-label forminator-repeater-label\">Vehicle Information<\/label><div class=\"forminator-all-group-copies forminator-repeater-field\"><div class=\"forminator-grouped-fields\" data-options=\"{&quot;is_repeater&quot;:false,&quot;min_type&quot;:&quot;custom&quot;,&quot;max_type&quot;:&quot;custom&quot;,&quot;min&quot;:1,&quot;max&quot;:9223372036854775807,&quot;add_text&quot;:&quot;Add item&quot;,&quot;remove_text&quot;:&quot;Remove item&quot;,&quot;action_element_type&quot;:&quot;button&quot;}\"><div class=\"forminator-row\"><div id=\"select-1\" class=\"forminator-field-select forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-form-2769__field--select-1_6a6d38243145c\" id=\"forminator-form-2769__field--select-1_6a6d38243145c-label\" class=\"forminator-label\">Type <span class=\"forminator-required\">*<\/span><\/label><select  id=\"forminator-form-2769__field--select-1_6a6d38243145c\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"1\" name=\"select-1\" data-default-value=\"\" data-placeholder=\"Select an option\" data-search=\"false\" data-search-placeholder=\"Select an option\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-2769__field--select-1_6a6d38243145c-label\"><option value=\"\"  >Select an option<\/option><option value=\"one\"  data-calculation=\"0\">Agricultural<\/option><option value=\"two\"  data-calculation=\"0\">Commercial Vehicle<\/option><option value=\"Industrial\"  data-calculation=\"0\">Industrial<\/option><option value=\"Marine\"  data-calculation=\"0\">Marine<\/option><option value=\"Passenger-Vehicle\"  data-calculation=\"0\">Passenger Vehicle<\/option><\/select><\/div><\/div><div id=\"select-2\" class=\"forminator-field-select forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-form-2769__field--select-2_6a6d38243145c\" id=\"forminator-form-2769__field--select-2_6a6d38243145c-label\" class=\"forminator-label\">Make <span class=\"forminator-required\">*<\/span><\/label><select  id=\"forminator-form-2769__field--select-2_6a6d38243145c\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"1\" name=\"select-2\" data-default-value=\"\" data-placeholder=\"Select\" data-search=\"false\" data-search-placeholder=\"Select\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-2769__field--select-2_6a6d38243145c-label\"><option value=\"\"  >Select<\/option><option value=\"one\"  data-calculation=\"0\">Agco<\/option><option value=\"two\"  data-calculation=\"0\">Audi<\/option><option value=\"BMW\"  data-calculation=\"0\">BMW<\/option><option value=\"Case\"  data-calculation=\"0\">Case<\/option><option value=\"Caterpillar\"  data-calculation=\"0\">Caterpillar<\/option><option value=\"Chevrolet\"  data-calculation=\"0\">Chevrolet<\/option><option value=\"Chrysler\"  data-calculation=\"0\">Chrysler<\/option><option value=\"CIL\"  data-calculation=\"0\">CIH<\/option><option value=\"CNH\"  data-calculation=\"0\">CNH<\/option><option value=\"Detroit-Diesel\"  data-calculation=\"0\">Detroit Diesel<\/option><option value=\"Dodge\"  data-calculation=\"0\">Dodge<\/option><option value=\"Deutz\"  data-calculation=\"0\">Deutz<\/option><option value=\"Fendt\"  data-calculation=\"0\">Fendt<\/option><option value=\"Fiat\"  data-calculation=\"0\">Fiat<\/option><option value=\"Ford\"  data-calculation=\"0\">Ford<\/option><option value=\"Freightliner\"  data-calculation=\"0\">Freightliner<\/option><option value=\"GMC\"  data-calculation=\"0\">GMC<\/option><option value=\"Hummer\"  data-calculation=\"0\">Hummer<\/option><option value=\"Hyundai\"  data-calculation=\"0\">Hyundai<\/option><option value=\"International\"  data-calculation=\"0\">International<\/option><option value=\"Isuzu\"  data-calculation=\"0\">Isuzu<\/option><option value=\"Iveco\"  data-calculation=\"0\">Iveco<\/option><option value=\"Jeep\"  data-calculation=\"0\">Jeep<\/option><option value=\"JCB\"  data-calculation=\"0\">JCB<\/option><option value=\"John-Deere\"  data-calculation=\"0\">John Deere<\/option><option value=\"Komatsu\"  data-calculation=\"0\">Komatsu<\/option><option value=\"Land-Rover\"  data-calculation=\"0\">Land Rover<\/option><option value=\"Kenworth\"  data-calculation=\"0\">Kenworth<\/option><option value=\"Man\"  data-calculation=\"0\">Man<\/option><option value=\"Mazda\"  data-calculation=\"0\">Mazda<\/option><option value=\"Mercedes-Benz\"  data-calculation=\"0\">Mercedes-Benz<\/option><option value=\"Mitsubishi\"  data-calculation=\"0\">Mitsubishi<\/option><option value=\"New-Holland\"  data-calculation=\"0\">New Holland<\/option><option value=\"Navistar\"  data-calculation=\"0\">Navistar<\/option><option value=\"Nissan\"  data-calculation=\"0\">Nissan<\/option><option value=\"Perkins\"  data-calculation=\"0\">Perkins<\/option><option value=\"Peterbilt\"  data-calculation=\"0\">Peterbilt<\/option><option value=\"Porsche\"  data-calculation=\"0\">Porsche<\/option><option value=\"Smart\"  data-calculation=\"0\">Smart<\/option><option value=\"Sterling\"  data-calculation=\"0\">Sterling<\/option><option value=\"Subaru\"  data-calculation=\"0\">Subaru<\/option><option value=\"Toyota\"  data-calculation=\"0\">Toyota<\/option><option value=\"Volkswagen\"  data-calculation=\"0\">Volkswagen<\/option><option value=\"Volvo\"  data-calculation=\"0\">Volvo<\/option><option value=\"WesternStar\"  data-calculation=\"0\">WesternStar<\/option><option value=\"Other\"  data-calculation=\"0\">Other<\/option><\/select><\/div><\/div><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_6a6d38243145c\" id=\"forminator-field-text-3_6a6d38243145c-label\" class=\"forminator-label\">Model <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"\" id=\"forminator-field-text-3_6a6d38243145c\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><div id=\"text-4\" class=\"forminator-field-text forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-4_6a6d38243145c\" id=\"forminator-field-text-4_6a6d38243145c-label\" class=\"forminator-label\">Year <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-4\" value=\"\" placeholder=\"\" id=\"forminator-field-text-4_6a6d38243145c\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-5\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-5_6a6d38243145c\" id=\"forminator-field-text-5_6a6d38243145c-label\" class=\"forminator-label\">Vehicle Identification Number <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"\" id=\"forminator-field-text-5_6a6d38243145c\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><div id=\"text-6\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-6_6a6d38243145c\" id=\"forminator-field-text-6_6a6d38243145c-label\" class=\"forminator-label\">Engine Model <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-6\" value=\"\" placeholder=\"\" id=\"forminator-field-text-6_6a6d38243145c\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><div id=\"text-7\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-7_6a6d38243145c\" id=\"forminator-field-text-7_6a6d38243145c-label\" class=\"forminator-label\">Engine Serial Number<\/label><input type=\"text\" name=\"text-7\" value=\"\" placeholder=\"\" id=\"forminator-field-text-7_6a6d38243145c\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"number-1\" class=\"forminator-field-number forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-1_6a6d38243145c\" id=\"forminator-field-number-1_6a6d38243145c-label\" class=\"forminator-label\">Hours of Use<\/label><input name=\"number-1\" value=\"\" placeholder=\"\" id=\"forminator-field-number-1_6a6d38243145c\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"\" data-decimals=\"0\" aria-required=\"false\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;&#039;, &#039;digits&#039;: &#039;0&#039;\" type=\"number\" step=\"any\" min=\"1\" max=\"150\" \/><\/div><\/div><div id=\"radio-1\" class=\"forminator-field-radio forminator-col forminator-col-4 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-1-6a6d38243145c-label\"><span id=\"forminator-radiogroup-radio-1-6a6d38243145c-label\" class=\"forminator-label\">Hours of Use<\/span><label id=\"forminator-field-radio-1-label-1\" for=\"forminator-field-radio-1-1-6a6d38243145c\" class=\"forminator-radio\" title=\"Meter\"><input type=\"radio\" name=\"radio-1\" value=\"one\" id=\"forminator-field-radio-1-1-6a6d38243145c\" aria-labelledby=\"forminator-field-radio-1-label-1\" data-calculation=\"0\"  \/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Meter<\/span><\/label><label id=\"forminator-field-radio-1-label-2\" for=\"forminator-field-radio-1-2-6a6d38243145c\" class=\"forminator-radio\" title=\"Estimated\"><input type=\"radio\" name=\"radio-1\" value=\"two\" id=\"forminator-field-radio-1-2-6a6d38243145c\" aria-labelledby=\"forminator-field-radio-1-label-2\" data-calculation=\"0\"  \/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Estimated<\/span><\/label><\/div><\/div><div id=\"date-2\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-picker_6a6d38243145c\" id=\"forminator-field-date-2-picker_6a6d38243145c-label\" class=\"forminator-label\">Failure Date <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-2\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-2-picker_6a6d38243145c\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-9\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-9_6a6d38243145c\" id=\"forminator-field-text-9_6a6d38243145c-label\" class=\"forminator-label\">Failure Miles\/Kms <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-9\" value=\"\" placeholder=\"\" id=\"forminator-field-text-9_6a6d38243145c\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><div id=\"date-3\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-3-picker_6a6d38243145c\" id=\"forminator-field-date-3-picker_6a6d38243145c-label\" class=\"forminator-label\">Date of Claim <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-3\" value=\"07\/31\/2026\" placeholder=\"\" id=\"forminator-field-date-3-picker_6a6d38243145c\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"group-4\" class=\"forminator-field-group forminator-col forminator-col-12 \"><label class=\"forminator-label forminator-repeater-label\">Problem Description<\/label><span class=\"forminator-description forminator-repeater-description\">Check the item(s) that most nearly describe the reported problem<\/span><div class=\"forminator-all-group-copies forminator-repeater-field\"><div class=\"forminator-grouped-fields\" data-options=\"{&quot;is_repeater&quot;:false,&quot;min_type&quot;:&quot;custom&quot;,&quot;max_type&quot;:&quot;custom&quot;,&quot;min&quot;:1,&quot;max&quot;:9223372036854775807,&quot;add_text&quot;:&quot;Add item&quot;,&quot;remove_text&quot;:&quot;Remove item&quot;,&quot;action_element_type&quot;:&quot;button&quot;}\"><div class=\"forminator-row\"><div id=\"checkbox-1\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field required\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-1-6a6d38243145c-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-1-6a6d38243145c-label\" class=\"forminator-label\">Problem Description <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-checkbox-1-1-6a6d38243145c-label\" for=\"forminator-field-checkbox-1-1-6a6d38243145c\" class=\"forminator-checkbox\" title=\"Will Not Start\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"will-not-start\" id=\"forminator-field-checkbox-1-1-6a6d38243145c\" aria-labelledby=\"forminator-field-checkbox-1-1-6a6d38243145c-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Will Not Start<\/span><\/label><label id=\"forminator-field-checkbox-1-2-6a6d38243145c-label\" for=\"forminator-field-checkbox-1-2-6a6d38243145c\" class=\"forminator-checkbox\" title=\"Hard Starting\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"hard-starting\" id=\"forminator-field-checkbox-1-2-6a6d38243145c\" aria-labelledby=\"forminator-field-checkbox-1-2-6a6d38243145c-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Hard Starting<\/span><\/label><label id=\"forminator-field-checkbox-1-3-6a6d38243145c-label\" for=\"forminator-field-checkbox-1-3-6a6d38243145c\" class=\"forminator-checkbox\" title=\"Low Power\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Low-Power\" id=\"forminator-field-checkbox-1-3-6a6d38243145c\" aria-labelledby=\"forminator-field-checkbox-1-3-6a6d38243145c-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Low Power<\/span><\/label><label id=\"forminator-field-checkbox-1-4-6a6d38243145c-label\" for=\"forminator-field-checkbox-1-4-6a6d38243145c\" class=\"forminator-checkbox\" title=\"Excessive Black Smoke\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Excessive-Black-Smoke\" id=\"forminator-field-checkbox-1-4-6a6d38243145c\" aria-labelledby=\"forminator-field-checkbox-1-4-6a6d38243145c-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Excessive Black Smoke<\/span><\/label><label id=\"forminator-field-checkbox-1-5-6a6d38243145c-label\" for=\"forminator-field-checkbox-1-5-6a6d38243145c\" class=\"forminator-checkbox\" title=\"Engine Surge\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Engine-Surge\" id=\"forminator-field-checkbox-1-5-6a6d38243145c\" aria-labelledby=\"forminator-field-checkbox-1-5-6a6d38243145c-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Engine Surge<\/span><\/label><label id=\"forminator-field-checkbox-1-6-6a6d38243145c-label\" for=\"forminator-field-checkbox-1-6-6a6d38243145c\" class=\"forminator-checkbox\" title=\"High Idle\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"High-Idle\" id=\"forminator-field-checkbox-1-6-6a6d38243145c\" aria-labelledby=\"forminator-field-checkbox-1-6-6a6d38243145c-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">High Idle<\/span><\/label><label id=\"forminator-field-checkbox-1-7-6a6d38243145c-label\" for=\"forminator-field-checkbox-1-7-6a6d38243145c\" class=\"forminator-checkbox\" title=\"Low Idle\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Low-Idle\" id=\"forminator-field-checkbox-1-7-6a6d38243145c\" aria-labelledby=\"forminator-field-checkbox-1-7-6a6d38243145c-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Low Idle<\/span><\/label><label id=\"forminator-field-checkbox-1-8-6a6d38243145c-label\" for=\"forminator-field-checkbox-1-8-6a6d38243145c\" class=\"forminator-checkbox\" title=\"Governor Will Not Respond to Load Change\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Governor-Will-Not-Respond-to-Load-Change\" id=\"forminator-field-checkbox-1-8-6a6d38243145c\" aria-labelledby=\"forminator-field-checkbox-1-8-6a6d38243145c-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Governor Will Not Respond to Load Change<\/span><\/label><label id=\"forminator-field-checkbox-1-9-6a6d38243145c-label\" for=\"forminator-field-checkbox-1-9-6a6d38243145c\" class=\"forminator-checkbox\" title=\"Will Not Low Idle -- Stalls\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Will-Not-Low-Idle----Stalls\" id=\"forminator-field-checkbox-1-9-6a6d38243145c\" aria-labelledby=\"forminator-field-checkbox-1-9-6a6d38243145c-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Will Not Low Idle -- Stalls<\/span><\/label><label id=\"forminator-field-checkbox-1-10-6a6d38243145c-label\" for=\"forminator-field-checkbox-1-10-6a6d38243145c\" class=\"forminator-checkbox\" title=\"Engine Under-Runs Low Idle Speed\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Engine-Under-Runs-Low-Idle-Speed\" id=\"forminator-field-checkbox-1-10-6a6d38243145c\" aria-labelledby=\"forminator-field-checkbox-1-10-6a6d38243145c-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Engine Under-Runs Low Idle Speed<\/span><\/label><label id=\"forminator-field-checkbox-1-11-6a6d38243145c-label\" for=\"forminator-field-checkbox-1-11-6a6d38243145c\" class=\"forminator-checkbox\" title=\"High Low Idle RPM\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"High-Low-Idle-RPM\" id=\"forminator-field-checkbox-1-11-6a6d38243145c\" aria-labelledby=\"forminator-field-checkbox-1-11-6a6d38243145c-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">High Low Idle RPM<\/span><\/label><label id=\"forminator-field-checkbox-1-12-6a6d38243145c-label\" for=\"forminator-field-checkbox-1-12-6a6d38243145c\" class=\"forminator-checkbox\" title=\"Engine Over-Runs High Idle Speed\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Engine-Over-Runs-High-Idle-Speed\" id=\"forminator-field-checkbox-1-12-6a6d38243145c\" aria-labelledby=\"forminator-field-checkbox-1-12-6a6d38243145c-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Engine Over-Runs High Idle Speed<\/span><\/label><label id=\"forminator-field-checkbox-1-13-6a6d38243145c-label\" for=\"forminator-field-checkbox-1-13-6a6d38243145c\" class=\"forminator-checkbox\" title=\"Overspeed\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Overspeed\" id=\"forminator-field-checkbox-1-13-6a6d38243145c\" aria-labelledby=\"forminator-field-checkbox-1-13-6a6d38243145c-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Overspeed<\/span><\/label><label id=\"forminator-field-checkbox-1-14-6a6d38243145c-label\" for=\"forminator-field-checkbox-1-14-6a6d38243145c\" class=\"forminator-checkbox\" title=\"Excessive Fuel Consumption\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Excessive-Fuel-Consumption\" id=\"forminator-field-checkbox-1-14-6a6d38243145c\" aria-labelledby=\"forminator-field-checkbox-1-14-6a6d38243145c-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Excessive Fuel Consumption<\/span><\/label><label id=\"forminator-field-checkbox-1-15-6a6d38243145c-label\" for=\"forminator-field-checkbox-1-15-6a6d38243145c\" class=\"forminator-checkbox\" title=\"Noisy Pump\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Noisy-Pump\" id=\"forminator-field-checkbox-1-15-6a6d38243145c\" aria-labelledby=\"forminator-field-checkbox-1-15-6a6d38243145c-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Noisy Pump<\/span><\/label><label id=\"forminator-field-checkbox-1-16-6a6d38243145c-label\" for=\"forminator-field-checkbox-1-16-6a6d38243145c\" class=\"forminator-checkbox\" title=\"Low Idle\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Low-Idle\" id=\"forminator-field-checkbox-1-16-6a6d38243145c\" aria-labelledby=\"forminator-field-checkbox-1-16-6a6d38243145c-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Low Idle<\/span><\/label><label id=\"forminator-field-checkbox-1-17-6a6d38243145c-label\" for=\"forminator-field-checkbox-1-17-6a6d38243145c\" class=\"forminator-checkbox\" title=\"Other Speeds\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Other-Speeds\" id=\"forminator-field-checkbox-1-17-6a6d38243145c\" aria-labelledby=\"forminator-field-checkbox-1-17-6a6d38243145c-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Other Speeds<\/span><\/label><label id=\"forminator-field-checkbox-1-18-6a6d38243145c-label\" for=\"forminator-field-checkbox-1-18-6a6d38243145c\" class=\"forminator-checkbox\" title=\"Engine Rough\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Engine-Rough\" id=\"forminator-field-checkbox-1-18-6a6d38243145c\" aria-labelledby=\"forminator-field-checkbox-1-18-6a6d38243145c-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Engine Rough<\/span><\/label><label id=\"forminator-field-checkbox-1-19-6a6d38243145c-label\" for=\"forminator-field-checkbox-1-19-6a6d38243145c\" class=\"forminator-checkbox\" title=\"Improper supply Pump Pressure\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Improper-supply-Pump-Pressure\" id=\"forminator-field-checkbox-1-19-6a6d38243145c\" aria-labelledby=\"forminator-field-checkbox-1-19-6a6d38243145c-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Improper supply Pump Pressure<\/span><\/label><label id=\"forminator-field-checkbox-1-20-6a6d38243145c-label\" for=\"forminator-field-checkbox-1-20-6a6d38243145c\" class=\"forminator-checkbox\" title=\"Fuel Leak\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Fuel-Leak\" id=\"forminator-field-checkbox-1-20-6a6d38243145c\" aria-labelledby=\"forminator-field-checkbox-1-20-6a6d38243145c-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Fuel Leak<\/span><\/label><label id=\"forminator-field-checkbox-1-21-6a6d38243145c-label\" for=\"forminator-field-checkbox-1-21-6a6d38243145c\" class=\"forminator-checkbox\" title=\"Lube Oil Dilution\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Lube-Oil-Dilution\" id=\"forminator-field-checkbox-1-21-6a6d38243145c\" aria-labelledby=\"forminator-field-checkbox-1-21-6a6d38243145c-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Lube Oil Dilution<\/span><\/label><label id=\"forminator-field-checkbox-1-22-6a6d38243145c-label\" for=\"forminator-field-checkbox-1-22-6a6d38243145c\" class=\"forminator-checkbox\" title=\"Accessories : Broken \/ Inoperative\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Accessories-:-Broken---Inoperative\" id=\"forminator-field-checkbox-1-22-6a6d38243145c\" aria-labelledby=\"forminator-field-checkbox-1-22-6a6d38243145c-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Accessories : Broken \/ Inoperative<\/span><\/label><label id=\"forminator-field-checkbox-1-23-6a6d38243145c-label\" for=\"forminator-field-checkbox-1-23-6a6d38243145c\" class=\"forminator-checkbox\" title=\"Other\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Other\" id=\"forminator-field-checkbox-1-23-6a6d38243145c\" aria-labelledby=\"forminator-field-checkbox-1-23-6a6d38243145c-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Other<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-1\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-1_6a6d38243145c\" id=\"forminator-field-textarea-1_6a6d38243145c-label\" class=\"forminator-label\">Description of Problem and Action Taken <span class=\"forminator-required\">*<\/span><\/label><textarea name=\"textarea-1\" placeholder=\"\" id=\"forminator-field-textarea-1_6a6d38243145c\" class=\"forminator-textarea\" style=\"--forminator-textarea-min-height:140px;\" aria-describedby=\"forminator-field-textarea-1_6a6d38243145c-description\" ><\/textarea><span id=\"forminator-field-textarea-1_6a6d38243145c-description\" class=\"forminator-description\">If parts were installed, identify below.<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-13\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-13_6a6d38243145c\" id=\"forminator-field-text-13_6a6d38243145c-label\" class=\"forminator-label\">Diagnostic Trouble Codes<\/label><input type=\"text\" name=\"text-13\" value=\"\" placeholder=\"\" id=\"forminator-field-text-13_6a6d38243145c\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-12\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-12_6a6d38243145c\" id=\"forminator-field-text-12_6a6d38243145c-label\" class=\"forminator-label\">Diagnostic Tool<\/label><input type=\"text\" name=\"text-12\" value=\"\" placeholder=\"\" id=\"forminator-field-text-12_6a6d38243145c\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"group-5\" class=\"forminator-field-group forminator-col forminator-col-6 \"><label class=\"forminator-label forminator-repeater-label\">Warrantied Parts Information<\/label><div class=\"forminator-all-group-copies forminator-repeater-field\"><div class=\"forminator-grouped-fields\" data-options=\"{&quot;is_repeater&quot;:false,&quot;min_type&quot;:&quot;custom&quot;,&quot;max_type&quot;:&quot;custom&quot;,&quot;min&quot;:1,&quot;max&quot;:9223372036854775807,&quot;add_text&quot;:&quot;Add item&quot;,&quot;remove_text&quot;:&quot;Remove item&quot;,&quot;action_element_type&quot;:&quot;button&quot;}\"><div class=\"forminator-row\"><div id=\"radio-2\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-2-6a6d38243145c-label\"><span id=\"forminator-radiogroup-radio-2-6a6d38243145c-label\" class=\"forminator-label\">Is the warrantied part a trim coded injector? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-2-label-1\" for=\"forminator-field-radio-2-1-6a6d38243145c\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-2\" value=\"one\" id=\"forminator-field-radio-2-1-6a6d38243145c\" aria-labelledby=\"forminator-field-radio-2-label-1\" data-calculation=\"0\"  \/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-2-label-2\" for=\"forminator-field-radio-2-2-6a6d38243145c\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-2\" value=\"two\" id=\"forminator-field-radio-2-2-6a6d38243145c\" aria-labelledby=\"forminator-field-radio-2-label-2\" data-calculation=\"0\"  \/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-3\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-3-6a6d38243145c-label\"><span id=\"forminator-radiogroup-radio-3-6a6d38243145c-label\" class=\"forminator-label\">Was the trim code applied when the injector was installed?<\/span><label id=\"forminator-field-radio-3-label-1\" for=\"forminator-field-radio-3-1-6a6d38243145c\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-3\" value=\"one\" id=\"forminator-field-radio-3-1-6a6d38243145c\" aria-labelledby=\"forminator-field-radio-3-label-1\" data-calculation=\"0\"  \/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-3-label-2\" for=\"forminator-field-radio-3-2-6a6d38243145c\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-3\" value=\"two\" id=\"forminator-field-radio-3-2-6a6d38243145c\" aria-labelledby=\"forminator-field-radio-3-label-2\" data-calculation=\"0\"  \/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-1\" class=\"forminator-field-upload forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-upload-1_6a6d38243145c\" id=\"forminator-field-upload-1_6a6d38243145c-label\" class=\"forminator-label\">Upload file<\/label><div class=\"forminator-file-upload \" data-element=\"upload-1_6a6d38243145c\" aria-describedby=\"forminator-field-upload-1_6a6d38243145c-description\"><input type=\"file\" name=\"upload-1\" id=\"forminator-field-upload-1_6a6d38243145c\" class=\"forminator-input-file\" accept=\".webp,.json,.xla,.xls,.xlt,.xlw,.xlsx,.doc,.docx,.pdf,.bmp,.png,.gif,.jpg,.jpeg,.jpe,image\/webp,application\/vnd.ms-excel,application\/vnd.openxmlformats-officedocument.spreadsheetml.sheet,application\/msword,application\/vnd.openxmlformats-officedocument.wordprocessingml.document,application\/pdf,image\/bmp,image\/png,image\/gif,image\/jpeg\" tabindex=\"-1\"><button id=\"forminator-field-upload-1_6a6d38243145c_button\" class=\"forminator-button forminator-button-upload\" data-id=\"forminator-field-upload-1_6a6d38243145c\">Choose File<\/button><span data-empty-text=\"No file chosen\">No file chosen<\/span><button class=\"forminator-button-delete\" style=\"display: none;\"><i class=\"forminator-icon-close\" aria-hidden=\"true\"><\/i><span class=\"forminator-screen-reader-only\">Delete uploaded file<\/span><\/button><\/div><span id=\"forminator-field-upload-1_6a6d38243145c-description\" class=\"forminator-description\">A screenshot of the applied trim code MUST be submitted as part of the supporting documentation for valid warranty consideration.<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-2\" class=\"forminator-field-upload forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-upload-2_6a6d38243145c\" id=\"forminator-field-upload-2_6a6d38243145c-label\" class=\"forminator-label\">Upload file<\/label><div class=\"forminator-file-upload \" data-element=\"upload-2_6a6d38243145c\" aria-describedby=\"forminator-field-upload-2_6a6d38243145c-description\"><input type=\"file\" name=\"upload-2\" id=\"forminator-field-upload-2_6a6d38243145c\" class=\"forminator-input-file\" accept=\".webp,.json,.xla,.xls,.xlt,.xlw,.xlsx,.pdf,.doc,.docx,.bmp,.png,.gif,.jpg,.jpeg,.jpe,image\/webp,application\/vnd.ms-excel,application\/vnd.openxmlformats-officedocument.spreadsheetml.sheet,application\/pdf,application\/msword,application\/vnd.openxmlformats-officedocument.wordprocessingml.document,image\/bmp,image\/png,image\/gif,image\/jpeg\" tabindex=\"-1\"><button id=\"forminator-field-upload-2_6a6d38243145c_button\" class=\"forminator-button forminator-button-upload\" data-id=\"forminator-field-upload-2_6a6d38243145c\">Choose File<\/button><span data-empty-text=\"No file chosen\">No file chosen<\/span><button class=\"forminator-button-delete\" style=\"display: none;\"><i class=\"forminator-icon-close\" aria-hidden=\"true\"><\/i><span class=\"forminator-screen-reader-only\">Delete uploaded file<\/span><\/button><\/div><span id=\"forminator-field-upload-2_6a6d38243145c-description\" class=\"forminator-description\">Valid trim code MUST be applied for valid warranty consideration. Please contact your service dealer or GCL Diesel for more information.<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-14\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-14_6a6d38243145c\" id=\"forminator-field-text-14_6a6d38243145c-label\" class=\"forminator-label\">Original TDS Invoice Number <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-14\" value=\"\" placeholder=\"\" id=\"forminator-field-text-14_6a6d38243145c\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-6\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-6-6a6d38243145c-label\"><span id=\"forminator-radiogroup-radio-6-6a6d38243145c-label\" class=\"forminator-label\">Are you submitting a part numbers and quantities in text or uploading an excel sheet? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-6-label-1\" for=\"forminator-field-radio-6-1-6a6d38243145c\" class=\"forminator-radio\" title=\"submitting a part numbers and quantities in text\"><input type=\"radio\" name=\"radio-6\" value=\"one\" id=\"forminator-field-radio-6-1-6a6d38243145c\" aria-labelledby=\"forminator-field-radio-6-label-1\" data-calculation=\"0\"  \/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">submitting a part numbers and quantities in text<\/span><\/label><label id=\"forminator-field-radio-6-label-2\" for=\"forminator-field-radio-6-2-6a6d38243145c\" class=\"forminator-radio\" title=\"Upload Excel Sheet\"><input type=\"radio\" name=\"radio-6\" value=\"two\" id=\"forminator-field-radio-6-2-6a6d38243145c\" aria-labelledby=\"forminator-field-radio-6-label-2\" data-calculation=\"0\"  \/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Upload Excel Sheet<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-4\" class=\"forminator-field-upload forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-upload-4_6a6d38243145c\" id=\"forminator-field-upload-4_6a6d38243145c-label\" class=\"forminator-label\">Upload file<\/label><div class=\"forminator-file-upload \" data-element=\"upload-4_6a6d38243145c\"><input type=\"file\" name=\"upload-4\" id=\"forminator-field-upload-4_6a6d38243145c\" class=\"forminator-input-file\" accept=\".jpg,.jpeg,.jpe,.gif,.png,.bmp,.tiff,.tif,.webp,.ico,.heic,.asf,.asx,.wmv,.wmx,.wm,.avi,.divx,.flv,.mov,.qt,.mpeg,.mpg,.mpe,.mp4,.m4v,.ogv,.webm,.mkv,.3gp,.3gpp,.3g2,.3gp2,.txt,.asc,.c,.cc,.h,.srt,.csv,.tsv,.ics,.rtx,.vtt,.mp3,.m4a,.m4b,.aac,.ra,.ram,.wav,.ogg,.oga,.flac,.mid,.midi,.wma,.wax,.mka,.rtf,.pdf,.class,.tar,.zip,.gz,.gzip,.7z,.psd,.xcf,.doc,.pot,.pps,.ppt,.wri,.xla,.xls,.xlt,.xlw,.mdb,.mpp,.docx,.docm,.dotx,.dotm,.xlsx,.xlsm,.xlsb,.xltx,.xltm,.xlam,.pptx,.pptm,.ppsx,.ppsm,.potx,.potm,.ppam,.sldx,.sldm,.onetoc,.onetoc2,.onetmp,.onepkg,.oxps,.xps,.odt,.odp,.ods,.odg,.odc,.odb,.odf,.wp,.wpd,.key,.numbers,.pages,.json,image\/jpeg,image\/gif,image\/png,image\/bmp,image\/tiff,image\/webp,image\/x-icon,image\/heic,video\/x-ms-asf,video\/x-ms-wmv,video\/x-ms-wmx,video\/x-ms-wm,video\/avi,video\/divx,video\/x-flv,video\/quicktime,video\/mpeg,video\/mp4,video\/ogg,video\/webm,video\/x-matroska,video\/3gpp,video\/3gpp2,text\/plain,text\/csv,text\/tab-separated-values,text\/calendar,text\/richtext,text\/vtt,audio\/mpeg,audio\/aac,audio\/x-realaudio,audio\/wav,audio\/ogg,audio\/flac,audio\/midi,audio\/x-ms-wma,audio\/x-ms-wax,audio\/x-matroska,application\/rtf,application\/pdf,application\/java,application\/x-tar,application\/zip,application\/x-gzip,application\/x-7z-compressed,application\/octet-stream,application\/msword,application\/vnd.ms-powerpoint,application\/vnd.ms-write,application\/vnd.ms-excel,application\/vnd.ms-access,application\/vnd.ms-project,application\/vnd.openxmlformats-officedocument.wordprocessingml.document,application\/vnd.ms-word.document.macroEnabled.12,application\/vnd.openxmlformats-officedocument.wordprocessingml.template,application\/vnd.ms-word.template.macroEnabled.12,application\/vnd.openxmlformats-officedocument.spreadsheetml.sheet,application\/vnd.ms-excel.sheet.macroEnabled.12,application\/vnd.ms-excel.sheet.binary.macroEnabled.12,application\/vnd.openxmlformats-officedocument.spreadsheetml.template,application\/vnd.ms-excel.template.macroEnabled.12,application\/vnd.ms-excel.addin.macroEnabled.12,application\/vnd.openxmlformats-officedocument.presentationml.presentation,application\/vnd.ms-powerpoint.presentation.macroEnabled.12,application\/vnd.openxmlformats-officedocument.presentationml.slideshow,application\/vnd.ms-powerpoint.slideshow.macroEnabled.12,application\/vnd.openxmlformats-officedocument.presentationml.template,application\/vnd.ms-powerpoint.template.macroEnabled.12,application\/vnd.ms-powerpoint.addin.macroEnabled.12,application\/vnd.openxmlformats-officedocument.presentationml.slide,application\/vnd.ms-powerpoint.slide.macroEnabled.12,application\/onenote,application\/oxps,application\/vnd.ms-xpsdocument,application\/vnd.oasis.opendocument.text,application\/vnd.oasis.opendocument.presentation,application\/vnd.oasis.opendocument.spreadsheet,application\/vnd.oasis.opendocument.graphics,application\/vnd.oasis.opendocument.chart,application\/vnd.oasis.opendocument.database,application\/vnd.oasis.opendocument.formula,application\/wordperfect,application\/vnd.apple.keynote,application\/vnd.apple.numbers,application\/vnd.apple.pages\" tabindex=\"-1\"><button id=\"forminator-field-upload-4_6a6d38243145c_button\" class=\"forminator-button forminator-button-upload\" data-id=\"forminator-field-upload-4_6a6d38243145c\">Choose File<\/button><span data-empty-text=\"No file chosen\">No file chosen<\/span><button class=\"forminator-button-delete\" style=\"display: none;\"><i class=\"forminator-icon-close\" aria-hidden=\"true\"><\/i><span class=\"forminator-screen-reader-only\">Delete uploaded file<\/span><\/button><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-3\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-3_6a6d38243145c\" id=\"forminator-field-textarea-3_6a6d38243145c-label\" class=\"forminator-label\">Part Numbers and Quantities <span class=\"forminator-required\">*<\/span><\/label><textarea name=\"textarea-3\" placeholder=\"\" id=\"forminator-field-textarea-3_6a6d38243145c\" class=\"forminator-textarea\" style=\"--forminator-textarea-min-height:140px;\" aria-describedby=\"forminator-field-textarea-3_6a6d38243145c-description\" ><\/textarea><span id=\"forminator-field-textarea-3_6a6d38243145c-description\" class=\"forminator-description\">Enter N\/A if none provided<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-4\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-4-6a6d38243145c-label\"><span id=\"forminator-radiogroup-radio-4-6a6d38243145c-label\" class=\"forminator-label\">Has the Part Been Replaced? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-4-label-1\" for=\"forminator-field-radio-4-1-6a6d38243145c\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-4\" value=\"one\" id=\"forminator-field-radio-4-1-6a6d38243145c\" aria-labelledby=\"forminator-field-radio-4-label-1\" data-calculation=\"0\"  \/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-4-label-2\" for=\"forminator-field-radio-4-2-6a6d38243145c\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-4\" value=\"two\" id=\"forminator-field-radio-4-2-6a6d38243145c\" aria-labelledby=\"forminator-field-radio-4-label-2\" data-calculation=\"0\"  \/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-15\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-15_6a6d38243145c\" id=\"forminator-field-text-15_6a6d38243145c-label\" class=\"forminator-label\">Replacement Part Number<\/label><input type=\"text\" name=\"text-15\" value=\"\" placeholder=\"\" id=\"forminator-field-text-15_6a6d38243145c\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div id=\"group-6\" class=\"forminator-field-group forminator-col forminator-col-6 \"><label class=\"forminator-label forminator-repeater-label\">Labour Reimbursement<\/label><div class=\"forminator-all-group-copies forminator-repeater-field\"><div class=\"forminator-grouped-fields\" data-options=\"{&quot;is_repeater&quot;:false,&quot;min_type&quot;:&quot;custom&quot;,&quot;max_type&quot;:&quot;custom&quot;,&quot;min&quot;:1,&quot;max&quot;:9223372036854775807,&quot;add_text&quot;:&quot;Add item&quot;,&quot;remove_text&quot;:&quot;Remove item&quot;,&quot;action_element_type&quot;:&quot;button&quot;}\"><div class=\"forminator-row\"><div id=\"radio-5\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-5-6a6d38243145c-label\" aria-describedby=\"forminator-radiogroup-radio-5-6a6d38243145c-description\"><span id=\"forminator-radiogroup-radio-5-6a6d38243145c-label\" class=\"forminator-label\">Labour Reimbursement Request<\/span><label id=\"forminator-field-radio-5-label-1\" for=\"forminator-field-radio-5-1-6a6d38243145c\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-5\" value=\"one\" id=\"forminator-field-radio-5-1-6a6d38243145c\" aria-labelledby=\"forminator-field-radio-5-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-5-6a6d38243145c-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-5-label-2\" for=\"forminator-field-radio-5-2-6a6d38243145c\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-5\" value=\"two\" id=\"forminator-field-radio-5-2-6a6d38243145c\" aria-labelledby=\"forminator-field-radio-5-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-5-6a6d38243145c-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><span id=\"forminator-radiogroup-radio-5-6a6d38243145c-description\" class=\"forminator-description\">To be considered for labour reimbursement, the following documents must be uploaded: Copy of document where failed items were originally installed and copy of document where failed items were replaced<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-3\" class=\"forminator-field-upload forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-upload-3_6a6d38243145c\" id=\"forminator-field-upload-3_6a6d38243145c-label\" class=\"forminator-label\">Upload file<\/label><div class=\"forminator-file-upload \" data-element=\"upload-3_6a6d38243145c\"><input type=\"file\" name=\"upload-3\" id=\"forminator-field-upload-3_6a6d38243145c\" class=\"forminator-input-file\" accept=\".webp,.json,.xla,.xls,.xlt,.xlw,.xlsx,.doc,.docx,.pdf,.jpg,.jpeg,.jpe,.png,.gif,.bmp,image\/webp,application\/vnd.ms-excel,application\/vnd.openxmlformats-officedocument.spreadsheetml.sheet,application\/msword,application\/vnd.openxmlformats-officedocument.wordprocessingml.document,application\/pdf,image\/jpeg,image\/png,image\/gif,image\/bmp\" tabindex=\"-1\"><button id=\"forminator-field-upload-3_6a6d38243145c_button\" class=\"forminator-button forminator-button-upload\" data-id=\"forminator-field-upload-3_6a6d38243145c\">Choose File<\/button><span data-empty-text=\"No file chosen\">No file chosen<\/span><button class=\"forminator-button-delete\" style=\"display: none;\"><i class=\"forminator-icon-close\" aria-hidden=\"true\"><\/i><span class=\"forminator-screen-reader-only\">Delete uploaded file<\/span><\/button><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit\"><span>Send Message<\/span><span aria-hidden=\"true\"><\/span><\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"de65b4b57a\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F2770\" \/><input type=\"hidden\" name=\"form_id\" value=\"2769\"><input type=\"hidden\" name=\"page_id\" value=\"2770\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/tdsautoparts.ca\/?page_id=2770\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><label for=\"input_44\" class=\"forminator-hidden\" aria-hidden=\"true\">Please do not fill in this field. <input id=\"input_44\" type=\"text\" name=\"input_44\" value=\"\" autocomplete=\"off\"><\/label><\/form><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Apply for your TDS Auto Parts Warranty Claim using this form Please try to provide as much information as possible to ensure a smooth and quick turnaround. DO NOT send any parts for warranty without getting a Return Warranty Authorization (RWA) number from TDS Auto Parts. \u00a0Our promise to you: The information you supply to [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"footnotes":""},"class_list":["post-2770","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/tdsautoparts.ca\/index.php?rest_route=\/wp\/v2\/pages\/2770","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/tdsautoparts.ca\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/tdsautoparts.ca\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/tdsautoparts.ca\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/tdsautoparts.ca\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=2770"}],"version-history":[{"count":19,"href":"https:\/\/tdsautoparts.ca\/index.php?rest_route=\/wp\/v2\/pages\/2770\/revisions"}],"predecessor-version":[{"id":2978,"href":"https:\/\/tdsautoparts.ca\/index.php?rest_route=\/wp\/v2\/pages\/2770\/revisions\/2978"}],"wp:attachment":[{"href":"https:\/\/tdsautoparts.ca\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=2770"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}