Product Service Form

• Document No.

• Claim Title

• Customer Name

• Purchase Order Number

• Purchase Order Date

  Date

• Invoice Date

  Date

• Prepared by

• Location
  Address

Product Information

• Type / Model

• Serial Number

• Photograph of Nameplate if accessible.

  Media

• Purchase Date

  Date

• Installation Date

  Date

• Failure Date

  Date

Site Set-up

• Set up was performed by an authorized person only?

  Yes

  No

  N/A

• Start-up verification was performed properly?

  yes

  no

• Pump Location:

  indoors

  outdoors

• Please photograph site where pump operates.

  Media

Application

• Pump Application:

  Select Aggricultural Domestic Iindustrial Single Unit Multiple Unit Booster Unit Other

  • Aggricultural
  • Domestic
  • Iindustrial
  • Single Unit
  • Multiple Unit
  • Booster Unit
  • Other

• If other please describe:

Other application

Working Condition

• Suction Condition

  Positive Suction Head

  Suction Lift

• Flow (lpm)

• Head (m)

• Power / Current (kW)

• Service Condition:

  Continuous

  Intermittent

• If Intermittent, number of stop/starts per hour:

Liquid Characteristics:

• Type:

• Temperature (c):

• Hazardous Liquid:

  Safe

  At Risk

  N/A

• Is the liquid free from particles? If no - describe.

  Yes

  No

  N/A

Electro-mechanical safety devices:

• Is the motor subjected to voltage variation?

  Yes

  No

  N/A

• Minimum Voltage Value

• Maximum Voltage Value

• Is the motor connected to ground?

  Yes

  No

  N/A

• Is it electrically protected?

  Yes

  No

  N/A

• If yes please specify protection:

  Select Fuses Overload Protector Thermal Cut Out other

  • Fuses
  • Overload Protector
  • Thermal Cut Out
  • other

• If Thermal Cut Out, Please Specify Settings:

• Type of Reset:

  Manual

  Automatic

• Is the pump protected from dry running operations?

  Yes

  No

  N/A

• If yes, Please Specify:

• Motor Cable Section (mm2)

• Motor Cable Length (m)

Fault / Problem Description

• Add any additional photographs.

  Media

• Add signature

  Sign