Bergstrom Climate Control Systems

RV Pre-Authorization Checklist


If you'd prefer to download and/or print the form, click here.

* Required
Customer Information
Contact Name *
Contact Phone Number *
Complaint *
Cause and Correction *
Date of Failure *
Date of Repair *
Labor Time Requested *
Part Number Needed *
System and Vehicle Information
RV Case Number
Complete Vehicle VIN *
Vehicle Year
Vehicle Make
Vehicle Model
Bergstrom Unit Part Number from Base Unit
Bergstrom Unit Serial Number from Base Unit
Vehicle In-Service Date *
Vehicle Mileage
Labor Rate
Repair Facility Name
Repair Facility Address
Please type the number 52660:*
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