HCB  Highway Clutch & Brake

187 Barrie Road Campbellfield Vic 3061

Clutch Kit Test / Claim Assessment Form

Date purchased………                                    Distributor  …………………………..................................................

Distributors Tax Invoice number…………

Vehicle Details

Make ……………..

Model……………..

Build Date ………..  Engine Size ............... Number of Cylinders...........

Odometer reading  when fitted……………………………………   Odometer reading when removed……………………………….

Customer Details

Name ...............................................................................................................

Address…………............................................................................................

Telephone number…………………………………………………………..

Workshop Fitters Details

Name:…………………………………………………………………………………..........

Workshop Address ………………………....... ABN...........................................................

Phone Number:.............................................

Description of problem

Clutch Cover & Clutch Plate                                                 Thrust Bearing

Slipping                        Vibration                                            Noisy ( High Pitched Squeal )

Shuddering                   Non Releasing                                  Noisy (Rattle)

Chattering                    Neutral Gear Rattle                         Continuous Bearing Noise

                                                                                                 Pulsating Pedal with Engine Running

Other ( Provide Details )…………………………………………………………………………………………….......

............................................................................................................................................................................................

Additional Information ( Circle if applicable )

Has the Vehicle been modified in any way                                       YES / NO

Was the Flywheel Machined prior to fitting a new Clutch         YES / NO

Was a new Spigot Bearing Fitted                                                     YES / NO

Please Circle if the vehicle was used in the followiing

RACING                    SPEED TIME TRIALS                  OFF ROAD DRIVING                       NORMAL ROAD

Return Complete Clutch Kit together this form and any relevant  Invoices for mechanical / machining works carried out .