FRI Auto Request Form New "*" indicates required fields CLAIM TYPE - CHECK ONE* Concession Retrofit Labor SPD - 60 Day Compressor / Outdoor Coil/ Ht Exch / Indoor Coil Retrofit Bulletin #*Dealer Account Number*Dealer Name*Submitter Name* First Last Submitter Email Address* Homeowner Name* First Last Homeowner Phone Number*Homeowner Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Describe work performed, reasons for consideration for amount requested*Model Number*Serial Number*Supporting Documents Drop files here or Select files Max. file size: 25 MB. This field is hidden when viewing the formSupporting DocumentsMax. file size: 55 MB.Start Date* MM slash DD slash YYYY Failed Date* MM slash DD slash YYYY Repair Date* MM slash DD slash YYYY Actual HoursRequested Labor Amount (This amount may be adjusted per Trane standard repair guidelines)Refrigerant (LBS) - Refrigerant paid at $19.00 / Lb MAX (R-22 or R-410A)Total Amount Requested (labor+refrigerant)*Local FSR*Anthony FlorilSteve WilsonJim NewellStephen SmithCameron FrankovitchTroy BowlinRobert ShiverJohn Fama
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