APPLICATION FORM FOR TYRE EXAMINATION

To ensure a prompt and accurate assessment of the complaint, all parts of this form must be fully completed by both the dealer and user.

It is also required that both dealer & user sign the respective parts of the form. Failure to do so will result in delays in processing and possibly an inappropriate conclusion.

It is important when returning tube type tyres to also return the tube (and flap).

NAME & FULL ADDRESS OF DEALER (1/4)

First name

Last name

Street Name & House Number

Post code

Dealers reference

Account No. with Manufacturer

Country

DETAILS OF TIRE, TUBE OR FLAP (2/4)

Tire sidewall explanation

Make

Type of tire

Number of tires

1

2

3

4

Tire size (Example: 120/70 R17)

Width

Aspect Ratio

Rim size

Load index

Speed Rating

Pattern

Tire 1

Full DOTCODE / Serial No's

Week code

Wheel position

Tire 2

Full DOTCODE / Serial No's

Wheel position

Tire 3

Full DOTCODE / Serial No's

Wheel position

Tire 4

Full DOTCODE / Serial No's

Wheel position

Is the tire new?

Yes

No

Was the product Original Equipment on the vehicle?

Yes

No

When was the tire purchased?

Tire milage

When purchased was the product part worn?

Yes

No

Upload image (optional)

Description of complaint

Vehicle details (3/4)

Registration No

Make

Model

Year of built

Engine c.c./ H.P

Speedometer Reading

Usage

Name & full address of user (4/4)

(If the applicant is not the User of the product, please enter both the User’s name and the name of the contact person handling this application on their behalf

Mr / Mrs / Ms

First name

Last name

Street Name & House Number

Postcode

City

Daytime Tel. No

Email

USER’ S DECLARATION

I/We certify that the product referred to above is my/our property and was fitted to my/our vehicle of which details are given above.
I/We consider the product has not given satisfactory service whilst on my/our vehicle and request you arrange examination by the manufacturer.
I/We declare that the above mentioned tyre/tube caused no damage to vehicles, property or injuries to people and hence no consequential claim will be made related to the tyre/tube detailed on this form.
I/We declare the details given above are correct to the best of my/our knowledge.
I/we agree that my/our personal data set out in this Form may be retained by the Dealer in its records and be passed on to the Manufacturer of the product (and/or its relevant affiliate) which may hold and process my/our information in order to deal with this application on the terms of its privacy made available on the manufacturer's website.

I have read and agree to the conditions of examination given above.

NAME & FULL ADDRESS OF DEALER (1/4)

DETAILS OF TIRE, TUBE OR FLAP (2/4)

Tire 1

Tire 2

Tire 3

Tire 4

Vehicle details (3/4)

Name & full address of user (4/4)

USER’ S DECLARATION

Cooper Tire & Rubber Company Europe