Q1.     Please enter the following: Name, Address, Phone Numbers, Organization  <br/><b>Organization:</b><input type="text" name="fname" value="Earhart Equipment Corporation" size="40" /><br/> <br />
             <!----   <b>Division:</b><input type="text" name="lname" value="" size="40" /> <br/>
                <b>ID#:</b> <input type="text" name="pat_id" value="9419" size="40" /> <br/><br/>-->
              <br />Q2. Please enter the following: Email  <br/> Email:<input type="text" name="email" value="mitch@earhartequipment.com" size="40" /><br/>  <br />Q3.  Client ID#:  <br/> 31667<br/>
      <br />Q4.  Machine Type Information:  <br/> Tractor<br/>
      <br />Q5.  Manufacturer:  <br/> CNH <br/>
      <br />Q6.  Product Name / Machine Model:  <br/> WORKMASTER 35<br/>
      <br />Q7.   Date of Commissioning (Delivery Date) MM/DD/YYYY:  <br/> 07/03/2014<br/>
      <br />Q8.  How many months is the warranty?  <br/> 36<br/>
      <br />Q9.  Hours on machine:  <br/> 60<br/>
      <br />Q10.  Serial Number:  <br/> 2211013869<br/>
      <br />Q11. Date of Failure (mm/dd/yyyy):  <br/> 04/08/2016<br/>
      <br />Q12.    Primary Problem Type  <br/> Electrical<br/>
      <br />Q13.  Causal Part  <br/>Continuation of W07435B
                   
        <br /><br />Q14.    Is Travel to be Reimbursed?:  <br/><input type="radio" id="2733" value="2733" name="16" checked=""> <label for="2733">  Yes  </label><br />
    <input type="radio" id="2734" value="2734" name="16" checked="checked"> <label for="2734"> <u> No </u> </label><br />
    <br />Q15.  Additional Comments  <br/>Yes
                   
        <br /><br />Q16.    Internal Tracking Reference Number (Skip or Use work order number if you don't have one)  <br/> N/A<br/>
      <br />Q17.   Work Order Number  <br/> W07435B1<br/>
      <br />Q18.  Meter Reading  <br/> N/A<br/>
      <br />Q19.  Meter Type  <br/> N/A<br/>
      <br />Q20.  Tractor Year  <br/> N/A<br/>
      <br />Q21.  Engine/Machine HP  <br/> N/A<br/>
      <br />Q22.  Group Code   <br/> N/A<br/>
      <br />Q23. How many segments is your claim? (Many manufacturers require the claim to be separated for each problem. Leaking coolant and oil are 2 problems, two segments.  <br/>1<br/><br />Q24.  Warranty Starter ID (auto-generated)  <br/> 9418<br/>
      <br />Q25.  Estimated value of claim based on work order. This optional and only used as an internal metric to determine how better to provide recovery and advocacy for out clients.  <br/> 0.00<br/>
      <br />