Lamp Failure Claim Form

Please note that this form is for direct VIQUA customers only. For indirect customers or end users, please contact your dealer or VIQUA support.
Reference Case Number (if known)

You may have a case number from technical support. If so, enter it here.
Lamp Part Number/Model Number*
Hidden
Date Code old string*
Date Code*
MM slash DD slash YYYY
Purchase Date (end user)
MM slash DD slash YYYY
When and how did the lamp fail?*
Controller Part Number Used with Lamp
Alarm on Controller
Controller Serial Number
Was a replacement part installed?
Did it fix the problem?
Replacement Lamp Part Number
Replacement Lamp Date Code
The date code would be located on the lamp beside the Hg symbol and be in the following format: #####-L###.
Upload Relevant Documents
Max. file size: 2 MB.
Images, videos, receipts
Requested Compensation*
VIQUA Direct Customer Information
VIQUA Direct Customer Company Name*
VIQUA Direct Customer ID
Street Address City State / Province / Region ZIP / Postal Code Country
VIQUA Direct Customer Contact Name*
VIQUA Direct Customer Email*
VIQUA Direct Customer Phone*

VIQUA Direct Customer Information