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Call: (713) 942-0808 |  6300 West Loop South Suite 280 Bellaire, Texas 77401

Ford Diesel Information Form

Contact Information
Name
 
Phone Number
 
  Email Address
 
Address
 
City
  State
  Zip
County
  County where vehicle was purchased
     
Vehicle Information
Model
  Model Year
Purchase Year
  Purchase Month
Dealer Name
  Dealer Location

Use of Vehicle
Heavy Commercial (tow heavy loads, RVs included on a daily basis for livelihood)
Light Commercial and Heavy Farm (lighter loads with medium to high mileage; i.e. repair vehicles with light trailer of tools, etc)
Passenger Professional or Light Farm (high mileage passenger use for business; occasional trailer or load)
Cowboy Cadillac (medium mileage passenger for personal use; rarely used to pull a trailer or load)

Current Mileage
      Annual Mileage

Severity of Problem
Total Breakdowns Severe (truck totally inoperable on more than one occasion; out of service for more than a month)
Multiple Failures (truck totally inoperable on at least one occasion; out of service for more than 2 weeks)
Chronic Service Trips (multiple warranty repairs but never left stranded; out of service less than 2 weeks)
Occasional (one or two warranty repairs but never left stranded; out of service less than 1 week)

Type of Problem
Engine replacement and/or more than 8 injectors
Fuel injectors (one to 8 replaced and/or injector harness)
Fuel Pump or oil pump replaced
Water in gas tank warning light (tank drained and/or replaced)
Hard start, poor power and fuel efficiency (excessive or unusual exhaust emissions)
Other. Please explain below.
 

Cost of repairs not covered by warranty. Do not include other damages.

Days out of service

Total of other damages paid or incurred by YOU (replacement rental vehicle, meals or lodging while stranded, lost profits or wages)

Additional Comments