Service Requests

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Simply, fill-in all appropriate information and either email us your service request or print and attach to equipment shipped in for service. We recommend careful packaging, utilizing a tracking number and appropriate shipping insurance. Immediately upon receipt, we will contact you regarding your request.

On-site service is offered in our local coverage area only. Please call to confirm availability.

If you have any questions or prefer to call in this information, please contact us at (215) 639-1565 during normal business hours and someone will be glad to help you.

We appreciate your business.

Today's Date:

Purchase Order #: (if Applicable)

First Name:

Last Name:

Company: (if Applicable)

Department:

Address:

City:

State: Choose AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

Zip:

Home Phone:

Work Phone:

Cell Phone:

Email:

Shipping Carrier: (if Applicable)

Tracking Number: (if Applicable)

Types of Service Requested:

List Make and Model Number of equipment requiring repair service:

Make (Item #1)
Model (Item #1)

Make (Item #2)
Model (Item #2)

Make (Item #3)
Model (Item #3)

Make (Item #4)
Model (Item #4)

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Insurance Claim Assignments

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Simply fill-in all applicable information below and email your claim assignment to Dial Electronics, Inc. Immediately upon receipt, we will contact all appropriate parties to arrange a convenient time for inspection.

A payment authorization is required from the insured in order to expidite the billing process. Please print the "Payment Authorization Form," fill-in all information, sign and fax to our office.

If you have any questions or prefer to call in this information, please contact us at (215) 639-1565 during normal business hours and someone will be glad to help you. We appreciate your business.

Today's Date: Time:

Insurance Company Information

Company:

Contact Name
First:
Last:

Telephone: Ext:

Cell Phone

Fax:

Email:

Address:

City:

State: Choose AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

Zip Code:

Public Adjuster/Restoration Company Information

Not Applicable

This is a: Choose Public Adjuster Restoration Company

Company:

Contact Name
First:
Last:

Telephone:Ext:

Cell Phone

Fax:

Email:

Address:

City:

State: Choose AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

Zip Code:

Insured/Claimant Information

 Copy Details from Insurance Company Information

Contact Name
First:
Last:

Company:

Address:

City:

State: Choose AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

Zip Code:

Location of Equipment (if different):

Home Phone:Ext:

Work Phone

Cell Phone:

Email:

Policy #:

Claim #:

Date of Loss: Choose January Februrary March April May June July August September October November December Choose 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Choose 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Type of Loss: Choose Fire Smoke Mold Water Surge Lightning Soot Impact Other

Equipment Damaged:

Comments:

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