Warranty Claim Submittal Form Claim Date MM slash DD slash YYYY Contact and Shipping InfoName of Person Submitting this Form* First Last Email of Person Submitting this Form* Furniture Owner* First Last Furniture Owner Customer Type*ConsumerCommercial End UserDealerIs Furniture Owner the Original Furniture Buyer?*YesNoWho is Paying Breezesta the Shipping Charges?*Furniture OwnerDealerShipping charges will be applied to approved claims and must be paid in order for the warranty repair or replacement order to be placed.Where PurchasedDealer/Store Name* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Address if Different from Submitter (where to send shipment notifications) Phone Number*Ship To Name First Last Ship To Address* Same as previous Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Address if Different from Submitter (where to send shipment notifications) Phone Number*Special Delivery InstructionsGuide to Description of ProblemThe warranty policy, based on Breezesta’s sole judgement, is to repair or replace furniture. Most claim issues are satisfied with parts for repair. Parts are always more expedient and typically easier to assemble than an entire furniture item. Please identify the problem as best you can to ensure the right part(s) is ordered for you. In the furniture industry, left and right arms and legs are identified as you are facing the furniture, not as you sit in it. Please provide the requisite photos for confirmation of left or right. Be specific as to the location of the damage on the furniture. If you have a copy of the installation instructions, write the exact part name in Description of the Problem field under Other. Otherwise, the terms below and an example of the Shoreline Adirondack Rocker parts are included here for guidance in identifying your damaged areas. Arms: Left arm; right arm; under arm support. Leg: Front or back leg; right or left leg; all legs; rocker leg. Back: Back frame; left side frame; right side frame; back slats; back assembly. Seat: Seat frame; seat slats; seat assembly; base assembly. Spreader: A poly lumber piece added for support to horizontally connect each side or legs. Table: Tabletop; table base spreader; end rail such as a perpendicular piece on a tabletop Joint: Where 2 poly pieces are joined/ held together (For example: a crack at joint) Hardware: Seat slings; swivel mechanism; screws; bolts; propel nuts. Claim InformationI have read the guide to description of problems* Yes Please list the damaged items. Item numbers can be found at www.Breezesta.com, dealer’s purchase order or invoice or your receipt.*Breezesta Item #Product NameColorQuantityDescription of Problem Description of Problems Hardware pulling out Hardware Rusted Splintering, similar to wood Right side (As you face the furniture) Left Side (As you face the furniture) Back Frame Crack(s)/ Break Seat Frame Crack(s/ Break Foot/leg crack(s)/ Break Rocker leg crack(s)/break Arm crack/break Under Arm Support crack/break Seat slats pulled out of frame Spreader Table bowing/warped Color Faded Swivel defective Glide mechanism defective Other (Free Text field) Order InformationIn order for your claim to be processed, please include the following items with this claim form: Photos of the Damaged Item(s). Include photo of each furniture item in its entirety in order for us to determine the correct design version, as well as a close up of the damaged area. Please submit at least 2 photos for each furniture item being claimed. Proof of purchase in the form of your customer receipt, dealer purchase order number, or dealer invoice. File Uploads* Drop files here or Select files Max. file size: 128 MB. Dealer Purchase Order # Dealer Invoice # Date of Purchase or Date Shipped* MM slash DD slash YYYY We hope you have been enjoying your Breezesta furniture and apologize for the issue that you have experienced. We look forward to resolving this claim for you. In order to prevent delays and enable us to process this claim, please make sure you have completed all required fields and uploaded proof of purchase and photos of each item with the damage clearly depicted. You only need to submit a claim form once, either emailed with the form attached or via this digital form. If your submission is successful, an on-screen message will show that you successfully submitted. If it does not submit, please page to the top to look for required fields that were not completed or minimize file sizes uploaded. If you are not receiving a success message, please download the warranty claim form to use the electronic Word document. Email the completed form and requested information to CLUwarranty@keter.com. Thank you for being a Breezesta customer! 80376