| Company Information: | |
| Company filling claim: | |
| Name of person filling claim: | |
| E-Mail of person filling claim: | |
| Phone of person filling claim: | |
| Customer ref no.: | |
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| Module Information: | |
| Order number: | |
| Type of module: | |
| Number of modules affected | |
| Serial Number(s) (one number pr line): | |
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| Installation Information | |
| Name of installation or customer: | |
| Name of Installer | |
| Address: | |
| State (only US): | |
| Zip: | |
| City: | |
| Country: | |
| Date of installation: | |
| Type of Installation: | |
| Size of installation (in kWp): | |
| Number of modules per string: | |
| Inverter type: | |
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| Description of defect: | |
| Type of fault: | |
| Date of defect detection: | |
| Location of the defect on the module: | |
| Describe the defect: | |
| How was the defect discovered? | |
| Date of previous inspection of the installation: | |
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| Attachments: | Picture whole frontside |
| | Picture whole back side |
| | Picture detailing the damage |
| | Picture of the pallet |
| | Picture of installation |