Customer Information
First Name *
Last Name *
Address (Street, City, Zip Code) *
Phone Number *
Email Address *
Contractor Information
First Name *
Last Name *
Company Name *
Company Address *
Phone Number *
Email Address *
Project Details
Date of Loaner Water Heater Install *
Make and Model of Heat Pump Water Heater *
Capacity of Heat Pump Water Heater *
Date of Inspection / Permit Closeout *
Invoice Total Cost *
Required Documents
After completing your form submission, a confirmation message will be displayed providing instructions on how to upload the following required documents:
Itemized customer invoice with product receipts and breakout of parts and labor costs
Permit approval documentation
Time stamped photos including nameplate of:
Original water heater
Loaner water heater
New Heat Pump Water Heater
If you don’t see this confirmation message, please check your email.
Acknowledgement
*
I certify the submitted information above is correct and verified.
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