East Coast Diesel LLC
New Customer Questionnaire
Customer Information
Company Name:
*
Main Phone:
How did you hear about us:
*
How would you prefer we access units for repairs:
Select Access Method
No preference, just get it done!
Customer will bring unit to the shop
Shop will service unit on-site
Shop will pick up unit and bring to the shop
Shop will tow unit
Contacts and Addresses
Who is requesting the repair:
*
Select Contact
Add a Contact
First Name:
*
Last Name:
*
Preferred Method of Contact:
*
Select Contact Method
Email
Phone
Cell Phone
Text Phone
Email:
Phone:
Cell Phone:
Save
Cancel
Who processes the bills and answers billing questions:
Select Contact
Add a Contact
First Name:
*
Last Name:
*
Preferred Method of Contact:
*
Select Contact Method
Email
Phone
Cell Phone
Text Phone
Email:
Phone:
Cell Phone:
Save
Cancel
Billing Address:
*
Select Address
Add an Address
Address Name:
*
Street Address:
*
City:
*
Country:
*
United States
Canada
State:
*
Postal Code:
*
Save
Cancel
Who makes the over all decisions at this location:
*
Select Contact
Add a Contact
First Name:
*
Last Name:
*
Preferred Method of Contact:
*
Select Contact Method
Email
Phone
Cell Phone
Text Phone
Email:
Phone:
Cell Phone:
Save
Cancel
Physical Address:
Select Address
Add an Address
Address Name:
*
Street Address:
*
City:
*
Country:
*
United States
Canada
State:
*
Postal Code:
*
Save
Cancel
Who makes most of the day to day decisions with the fleet:
Select Contact
Add a Contact
First Name:
*
Last Name:
*
Preferred Method of Contact:
*
Select Contact Method
Email
Phone
Cell Phone
Text Phone
Email:
Phone:
Cell Phone:
Save
Cancel
Who authorizes the repairs on the fleet:
*
Select Contact
Add a Contact
First Name:
*
Last Name:
*
Preferred Method of Contact:
*
Select Contact Method
Email
Phone
Cell Phone
Text Phone
Email:
Phone:
Cell Phone:
Save
Cancel
Billing Information
Payment Method:
*
Select Payment Method
Cash
Check
Credit Card
Direct Deposit
New Unit Questionnaire
Please fill out the new questionnaire accurately. The information you input will be used to determine many factors of this unit.
Identification
What type of chassis is this unit:
*
Select Unit Type
CONSTRUCTION EQUIPMENT
Fleet Vehicle
Garda Unit's
Light Duty
Medium Duty Vehicle
Misc
PICKUP TRUCK
Tractor
Trailer
Two Men Fleet
VIN:
*
Unit Number:
*
Unit Nickname:
License Plate:
Usage & Components
Assistance in tracking preventive maintenance:
*
Select Option
Yes
No
How do you want to track preventive maintenance intervals:
By Chassis Mileage
By Engine Hours
Do not track
Chassis mileage as of today:
Miles
Engine hours as of today:
Miles
What type of brake system does this unit have?
Air
Air over Hydraulic
Hydraulic
Is the unit assigned to one driver?
No
Yes
What is the primary driving condition of the unit?
City
Open Road
Some of Both
Does the unit routinely drive off paved roads?
No
Yes
Is the engine required to run to operate auxillary components on the unit?
No
Yes
What type of exhaust system does it have?
Diesel Exhaust Fuel (DEF)
Diesel Particular Filter (DPF)
Other
What type of fuel does the engine use?
CNG
Diesel
Gas
LPG
Does the unit have a PTO driven component?
No
Yes
What is the units primary purpose?
What type of transmission does the unit have?
Automatic
Manual
Manual with Auto Shift
How many miles or hours does the unit operate each day? (Average)
1. Less than 50 miles or 2 hours a day
2. Between 50 to 100 miles or 2 to 5 hours a day
3. Between 100 to 150 miles or 5 to 8 hours a day
4. Between 150 to 200 miles or 8 to 10 hours a day
5. Between 200 to 250 miles or 10 to 15 hours a day
6. Between 250 to 300 miles a day
8. Between 350 to 400 miles a day
9. More than 400 miles a day
Select the applicable components on the unit:
After Hours labor
Brake's
Chassis
Engine
IN-SHOP SERVICES
Lift
ON-SITE SERVICES
Road Service
Service Item
Transmission
Describe any other component(s) on the unit that are not listed above:
Scheduling & Authorization
When is this unit usually in use and unavailable for repair?
This information will be used to access the unit please be as accurate as possible. Thank you.
Where is this unit primarily located when not in service:
*
Select Address
Add an Address
Address Name:
*
Street Address:
*
City:
*
Country:
*
United States
Canada
State:
*
Postal Code:
*
Save
Cancel
How would you prefer we access the unit for repairs:
*
Select Access Method
No preference, just get it done!
Customer will bring unit to the shop
Shop will service unit on-site
Shop will pick up unit and bring to the shop
Shop will tow unit
Notes
Service Request Questionnaire
Complaints / Problems / Requests
A complaint is an issue you are having with the unit. Please describe the problem or request as thoroughly as possible.
The better you describe the problem, the better chance we have of identifying and repairing.
For example, "The A/C works great in the morning but in the afternoon it slowly starts blowing hot." If you have multiple issues/complaints, add them separately by clicking the "Add Another Complaint" button.
Describe first complaint, problem, or request:
*
How urgent is this:
*
Schedule as soon as possible
Schedule repair today
Emergency - Get this fixed right away
Remember for the next visit
Add another
Step 3: Scheduling & Authorization
When will the unit be available for repairs:
The unit MUST be accessed at the above date and time.
Available
Now
When would you like the unit back:
Return ASAP
How would you like us to access the unit:
*
Select Access Method
No preference, just get it done!
Customer will bring unit to the shop
Shop will service unit on-site
Shop will pick up unit and bring to the shop
Shop will tow unit
Where will this unit be located for access:
*
Select Address
Temporary Address (please put address in the Helpful Notes below)
Add A New Address
Address Name:
*
Street Address:
*
City:
*
Country:
*
United States
Canada
State:
*
Postal Code:
*
Save
Cancel
Helpful Notes:
Would you like the shop to deliver the unit:
*
Select One
No - Customer will pick up unit from shop
Yes - Shop will return unit to customer
Where would you like this unit delivered:
*
Select Address
Temporary Address (please put address in the Helpful Notes below)
Add A New Address
Address Name:
*
Street Address:
*
City:
*
Country:
*
United States
Canada
State:
*
Postal Code:
*
Save
Cancel
Helpful Notes:
PO Number:
Note:
Submit