2026 Steam Boiler Wiring Labor Redemption Form

This form must be filled out completely (all fields are required) and signed by a service company representative, stating that the steam boiler wiring modification was performed as described on the product bulletin. Once this service (and repair if needed) is performed, and this form is completed and submitted as indicated below, the service company is eligible to receive a $250 check as compensation.

Please fill out the form below.

Click the “SUBMIT” button when completed.

PLEASE NOTE: only one form per boiler will be accepted for compensation.

2026 Steam Boiler Wiring Labor Redemption Form

Servicing Company Information

Company Name(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name(Required)

First Last

Phone(Required)

Email(Required)

Boiler Information

Boiler Model Number(Required)

Boiler Serial Number(Required)

Date of Inspection(Required)

Date of Repair(Required)

Conditions(Required)

Zero Wiring Conditions Found

Boiler Wiring Condition #1 Present and Corrected

Boiler Wiring Condition #2 Present and Corrected

Homeowner Information

Homeowner Name(Required)

First Last

Homeowner Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Acknowledgement of Service Company Representative

By entering my name below, I attest that all of the information provided on this form, and associated with the boiler modification specified above is accurate, true, and complete to the best of my knowledge.

Service Company Representative Name(Required)