Quick Order Form

coolCARE Quick Order Form
Company Name*
Account #
Skip if uncertain
Dealer Confirmation Email*
example@example.com
Dealer Confirmation Email 2
example@example.com
Order with a Warranty Certificate?

YesNo
Manufacturer Warranty Certificate*

Equipment must have been installed less than 2 years from order date
Cancelof
Customer Detail
Dealer PO:*
Purchase Order
Agreement Charge $*
What the customer paid for the warranty.
Policy Holder Name

First NameLast Name
Policy Holder Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Policy Holder Email
example@example.com
Equipment Detail

Full System 1 Registration

Full System 2 Registration

Full System 3 Registration

Full System 4 Registration

Full System 5 Registration

Ductless Split System Registration

Single Equipment 1 Coverage

	Model #	Serial #	Size	Brand
Equipment
Optional

Single Equipment 2 Coverage

	Model #	Serial #	Size	Brand
Equipment
Optional

Single Equipment 3 Coverage

	Model #	Serial #	Size	Brand
Equipment
Optional

Single Equipment 4 Coverage

	Model #	Serial #	Size	Brand
Equipment
Optional

Single Equipment 5 Coverage

	Model #	Serial #	Size	Brand
Equipment
Optional

Coverage Section
Install Type:*
Equipment Type:*
Example AC Full System / Heat Pump Full System
Coverage Type*
Labor Coverage Length: (years)*
Labor Rate*
Parts Length: (years)
Are there multiple systems on the attached documents?

NoYes
Do you have any added accessories you need coverage for?

NoYes
Additional Accessory Options

Air CleanerDehumidifierHumidifierThermostat (additional to full system or single component job)Zoning System (Single Zone)Zoning System (Up to 4 Zones)

Accessory Coverage 1

	Model #	Serial #	Size	Brand
Equipment
Optional

Zoning System Coverage

THANK YOU Your Order is on the way! ONCE PLACED YOU'LL RECIEVE AN EMAIL WITH UPDATED STATUS AND ORDER NUMBER.
Order Status

ApprovedDenied
Order #
Should be Empty:

coolCARE Quick Order Form