Niroflex Swap Out Claim Form

Company Name*

Physical Address*

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

Mailing Address if Different than Street Address*

Same as Physical Address

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

Contact Name*

First Last

Contact Title or Position*

Contact Phone*

Contact Email*

Distributor name who sold the new Niroflex gloves*

Date of Purchase*

1st Niroflex glove style purchased*

1st Niroflex glove style purchased quantity*

2nd Niroflex glove style purchased

2nd Niroflex glove style purchased quantity

Upload trade in gloves photos*

Files accepted: jpg, jpeg, png, pdf, gif Max files: 5 Max upload size: 10MB

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, gif, Max. file size: 10 MB, Max. files: 5.

Upload proof of purchase (invoice copy)*

Files accepted: jpg, jpeg, png, pdf Max files: 1 Max upload size: 4MB

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 4 MB, Max. files: 1.