Daimler Vans Upfitter Portal - Delayed Warranty Form

All fields with * are mandatory.

Upfitter Token: *

VIN Number: *

Date in Service: * (mm/dd/yyyy)

Mileage: *

First Name or Company Name: *

Last Name:

Customer Address: *

Address Line 2:

Zip Code: *

City: *

State:

Customer Phone (Day): *

Customer Email:

By Submitting this Form on Date of 12/18/2018: *

I understand that all information regarding this vehicle (e.g., Recall and Field Service Campaigns, etc.) will be mailed to the above (Customer) name and address.
I acknowledge receipt of the applicable Owner's Service and Warranty Information book and accept the terms and conditions set forth therein including the Limited Warranty, Warranty disclaimer, and Limitation of Liability.
I certify that I have received the applicable Maintenance Manual and the Operator's Manual.
I acknowledge that I have been instructed on how to correct fifth wheel operation (if applicable).
I acknowledge that the Federal Safety Standards and Emission stickers are affixed to the driver's door frame.