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 - Select - Under 33,000 mi 34,000 - 65,000 mi 66,000 - 99,000 mi Over 100,000 mi

Annual Mileage - Select - Over 36,000 mi 24,000 - 36,000 mi 16,000 - 24,000 mi Under 24,000 mi

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.
- Select - Over $10,000.00 Over $4,000.00 but Under $10,000.00 Under $4,000.00

Days out of service
- Select - Over 30 Days 15 - 29 Days 5 - 14 Days Under 5 Days

Total of other damages paid or incurred by YOU (replacement rental vehicle, meals or lodging while stranded, lost profits or wages)
- Select - Over $10,000.00 Over $4,000.00 but Under $10,000.00 Under $4,000.00

Additional Comments