NV Cargo - CLAIM WORKSHEET

Instructions: The purpose of this Claim Worksheet is to gather claim information from customer.
Once complete, information must be entered on the NCV Dealer Portal at nnanet.com.

DEALERSHIP INFORMATION:

Dealer Name: Contact Name:

Dealer Code: Contact Email:

Contact Phone:

CUSTOMER INFORMATION:
Vehicle Identification Number (VIN):
Business Name: _____________________________________________________________

Mailing Address: ____________________________________________________________

City/State/ZIP: ______________________________________________________________ Vehicle/Model Type: Delivery Date:

Customer Name: ____________________________________________________________ NV1500 _______ / _______ / ____________

NV2500 HD
Customer Phone: ____________________________________________________________ NV3500 HD
Customer Email: ____________________________________________________________ Customer Eligibility Business Documentation
Type of Business A copy of ONE of these documentations MUST be maintained in the deal jacket
Local Delivery Utilities/Municipalities for audit purposes.
Retail Trade Hotel/Restaurant Business License
Wholesale Trade Health Care Service Copy of DBA (Doing Business As) or Assumed Name Document
Construction Real Estate Articles of Incorporation
Maintenance/Repair Social Services Sales Tax License
Manufacturing State or Federal Forms showing a Federal Tax Identification Number
Other __________________________________________________________ Nissan FAN Code
D & B Listing
Delivery Type Municipal Business License
Fleet-tail Fleet State or Federal Authorized Business website (MUST have a .gov web address)
Retail Certification Code ______________ State Occupational License for Trade (ex. Plumber, Electrician, Contractor)

NCV INCENTIVE OPTIONS Customers Can Choose One NCV Incentive Option Per VIN
No-Charge Commercial Upfit Packages MSRP Accessories for Commercial Upfit Packages
(4484) Standard Roof Cargo Management $2,160 (Accessories must be ordered in conjunction
(4976) Standard Roof 3-Bar Utility $1,850 with a Commercial Upfit Package) MSRP
(4957) Standard Roof E-Z Load Utility $1,950 Standard Roof Max Comfort Wing Kit $ 79.95
(4519) High Roof Cargo Management $2,270 High Roof Max Comfort Wing Kit $ 79.95
(4520) High Roof Utility $1,860 RR Window Screens $ 125.00
Aluminum Conduit Holder 10'6"* $ 471.35
Vocational Commercial Upfit Packages 8" Door for Shelving $ 84.95
(w/customer responsibility) Partition Door Kit $ 73.50
(4686) Standard Roof General Service ($625.00 CR) $3,075 *Only available on standard roof models
(4687) Standard Roof Electrical ($1,121.00 CR) $3,800
(4688) Standard Roof Security ($882.00 CR) $3,465 Adrian Steel Distributor:
(4689) Standard Roof Cable ($549.00 CR) $2,970
(4690) Standard Roof HVAC ($992.00 CR) $3,625 Distributor Name: __________________________________________________
(2255) Standard Roof Locksmith ($1,900.00 CR) $4,925
City: _______________________________________ State: _______________
(4686) High Roof General Service ($625.00 CR) $3,165
(4687) High Roof Electrical ($1,121.00 CR) $3,890 These upfit packages are not covered under NNA warranty. Adrian Steel van and pickup
(4688) High Roof Security ($882.00 CR) $3,555 equipment is warranted to be free from defects in material and workmanship, under
(4689) High Roof Cable ($549.00 CR) $3,060 normal use and service, for a period of three years or 36,000 miles, whichever occurs first,
(4690) High Roof HVAC ($992.00 CR) $3,715 from the date of delivery to the original retail purchaser when installed by an authorized
(2255) High Roof Locksmith ($2,400.00 CR) $5,495 Adrian Steel distributor.

NCV Graphics Package MSRP NCV Graphics Package MSRP

NVS5 Standard Roof Level 1: (Complimentary) 70 Sq Ft $1,300 NVH5 High Roof Level 1: (Complimentary) 70 Sq Ft $ 1,300
NVS6 Standard Roof Level 2: 125 Sq Ft ($410 CR) $2,100 NVH6 High Roof Level 2: 175 Sq Ft ($812 CR) $ 2,538
NVS7 Standard Roof Level 3: 225 Sq Ft ($1,101 CR) $3,500 NVH7 High Roof Level 3: 275 Sq Ft ($1,390 CR) $ 3,800
NVS8 Standard Roof Level 4: 375 Sq Ft ($2,177 CR) $4,688 NVH8 High Roof Level 4: 425 Sq Ft ($2,468 CR) $ 5,206
These graphics packages are not covered under NNA warranty. Modagrafics installations are warranted to be free from defects in material and workmanship, under normal use and service,
for a period of three years or 36,000 miles, whichever occurs first, from the date of delivery to the original retail purchaser when installed by an authorized Modagrafics installer.
Commercial Rebate Fleet units reported sold as fleet (sales code type 2) are not eligible.
Commercial Rebate (To verify eligible cash amount available at time of delivery, and other sales type restrictions that may apply, see the Official Program Rules.)
Customer Name (Please Print) Date Authorized Dealer Representative (Please Print) Date

Customer Signature Date Authorized Dealer Representative Signature Date

NCV Program Headquarters 800-566-7500 (9:00 a.m. 5:00 p.m. Central) 04/1/2015 03/31/2016
File this copy in the deal jacket 4-1-2015

Page 1 of 3