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COMPONENT WEAR ANALYSIS FOR VEHICLE FLUIDS PROCESSING FORM
COMPONENT WEAR ANALYSIS FOR VEHICLE FLUIDS PROCESSING FORM
ocws
2014-01-15T12:03:01-05:00
Please complete one form to be included along with oil for
each
component sampled.
Sample ID #
Claim #
Investigator Case #
VIN/Serial #
Case Name/Insured
Investigator
*
Company/Department
Phone Number
Email Address
Vehicle Make
*
Vehicle Model
*
Vehicle Year
*
Comonent Sampled and Component Information
Checkboxes
Engine
Transmission
Fuel Type
Transmission Type
Component Manufacturer
Component Model
Oil Manufacture
Oil Brand/Type
Oil Grade
Sump Capacity
Volume
Gal
Qt
L
Makeup Oil Added
Radio Buttons
Gal
Qt
L
Sample Date
Fuel Consumed since last sample
Miles/Hours since new/overhaul
Miles/Hours since last oil change
Filter Changed
Yes
No
Oil Changed
Yes
No
Additional Comments or Information
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