Device Protection Insurance Claim Facilitation Form
Use this form to submit the details needed to facilitate a device protection insurance claim.
Claimant and Contact Details
Full Name
*
First Name
Middle Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Device and Policy Information
Device brand
*
Device model
*
Device serial number or device ID
Policy number
*
Claim Details and Supporting Information
Claim Type
*
Please Select
Accidental Damage
Theft
Loss
Screen Damage
Battery Issue
Other
Date of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Brief Description of What Happened
*
Supporting Evidence Upload
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Submit Claim
Should be Empty: