Claimant (Submitted by)
* Name or Company Name:
* Phone:
Owner/Property
* Name:
* Owner Phone:
* Address:
* City:
* State/Province:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
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Newfoundland
Northwest Territory
Nova Scotia
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon Territory
Other/Not Listed
* ZIP Code:
Mailing Address (if different):
Type of Structure
House
Apartment
Garage
Manufactured Home
Commercial Building
Installer
Name:
Phone Number:
Address:
City:
State/Province:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Northwest Territory
Nova Scotia
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon Territory
Other/Not Listed
ZIP Code:
At the time of installation, was this a new structure?
Yes
No
If no, was the product removed?
Yes
No
Was felt (underlayment) used under the shingles?
Yes
No
Unknown
Supplier
Name:
Phone Number:
Address:
City:
State/Province:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Northwest Territory
Nova Scotia
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon Territory
Other/Not Listed
ZIP Code:
What Owens Corning product did you purchase (if known)?
Style:
Color:
Warranty Years:
* Description of problem
* Total square feet of roof:
* Percentage affected:
Which areas are affected?
All
Front
Back
Left side
Right side
Our preferred method of communication is email.
* Would you mind if we correspond with you via email?
Yes
No
E-mail Address:
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