SPT_F-017-45-EN-Rev7

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Asurion Documentation Process: Sprint REQUIRED Steps to Complete Your Claim 1 2 3 Fill out the Claim Affidavit, being sure to sign the document Attach a photocopy of a Valid ID (See Examples of Valid IDs below) Forward your documents to Asurion by mail or fax Examples of Valid Personal Identification The following types of personal identification will be considered valid forms for this process: Drivers license (US or Canada) Matricular Consular ID (Mexico) State or Federally issued ID card US m
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  Control# F-017-45-EN Rev 06 EDT: 11/1/07 RDT: 5/11/10   Asurion Documentation Process: Sprint REQUIREDSteps to Complete Your Claim   1 Fill out the Claim Affidavit, being sure to sign the document   2 Attach a photocopy of a Valid ID (See Examples of Valid IDs below)   3 Forward your documents to Asurion by mail or fax  Examples of Valid Personal Identification The following types of personal identification will be considered valid forms for this process:   Drivers license (US or Canada)   State or Federally issued ID card   US or foreign passport   Matricular Consular ID (Mexico)   US military ID card (Active or Retired)   Important Reminders: The name on the ID must match the name of the primary account holder. If the name does not match, then additionaldocumentation may be required. Increasing the size of the ID and lightening the ID before faxing assists with thereview of your documents, and helps to prevent delays in claim processing.All forms of identification must be legible, unaltered, and legitimate. The ID also cannot be expired. If the ID appearsaltered, forged, or not legitimate, we will not be able to proceed with your claim.Student IDs, work IDs, birth certificates and Social Security cards are not acceptable as valid identification. EXAMPLES  –   The following are some examples of valid forms of photocopied personal identifications :    Drivers License State or Federally Issued US or Foreign Passport Matricular Consular ID US Military ID Card Please handwrite the number of the wireless device you are claiming on your ID before faxing. Finding your phone model: The easiest way to find the make and model of the phone you are claiming is to take off the back cover and battery.The make and model should be listed near the barcode on the back of the phone.If you do not have the phone, you may want to check your receipt from the purchase of the phone, your serviceagreement, the box the phone came in, a recent copy of your bill or your Sprint account at http://www.sprint.com/ .  All documents must be legible. Once we receive the items listed above, we will complete our review of your claim.You must return all documentation to the address listed on the affidavit within 60 days of the date you requestedyour replacement as provided in the Coverage Certificate or your claim may be denied. If you have any questions,please contact us at 1-800-584-3666. For the Equipment Protection Program: Underwritten by Continental Casualty Company, a CNA company. Program agent: Asurion Protection Services,LLC (In California, Asurion Protection Services Insurance Agency, LLC (CA License Number: OD63136); in Puerto Rico, Asurion Protection Service ofPuerto Rico, Inc. Puerto Rico Resident Agent Jorge J. Amadeo, Eastern America Insurance Agency, Inc.)*In California, Asurion Protection Services Insurance Agency, LLC (CA License Number: OD63136); in Puerto Rico, Asurion Protection Service of PuertoRico, Inc. Puerto Rico Resident Agent Jorge J. Amadeo, Eastern America Insurance Agency, Inc.     Instructions DO NOT FAX THIS PAGE     Control# F-017-45-EN Rev 06 EDT: 11/1/07 RDT: 5/11/10   Sprint Sworn Affidavit and Proof of Loss Statement Mail Documents to:Asurion Protection Services, LLC*Attn: Review Team (ERP)P.O. Box 413886Kansas City, MO 64141-3886   OR Fax documents to:1-888-832-0511   ALL FIELDS ARE REQUIRED ANDMUST BE FILLED IN (PLEASE PRINT)USING BLUE OR BLACK INK. IMPORTANT LEGAL NOTICE: Any person who knowingly and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete, or misleading information is guilty of insurance fraud, which is a crime. All claim files and documentation, including this affidavit, are subject to inspection by the various State Departments of Insurance.   Claimed Wireless Device Number   () - I. Personal Information of Account Holder: Account Holder’s First and Last Name:  ____________________________________________________________  Daytime Phone Number: _______________________ Evening Phone Number: _________________________  E-mail Address: _____________________________________________________________________________ Mailing Address: _____________________________________________________________________________ City: ____________________________________________ State: __________ Zip Code: ________________   2. Equipment and Claim Details Phone Manufacturer (Ex. Blackberry, Samsung, LG, etc.): Model (Ex. Rumor, Touch, 8830, etc.):Check one (1) of the following  –   Your phone was…  Lost Stolen Damaged MalfunctioningDate of occurrence : __________________ Place of occurrence: _______________________________________   Detailed description on what happened to your phone: ________________________________________________  ___________________________________________________________________________________   Note:  If your phone was damaged or malfunctioning, you are required to return it to Asurion upon receipt of your replacement phone.   3. Attach Photocopy of Your Valid Government Issued Photo ID (Please be sure to lighten and enlarge your ID, and clearly write your claimed wireless number on it to match to your claim)   Check type of photo ID you are attaching Drivers License State or Federally Issued IDPassport Military ID Matricular Consular ID EXAMPLES  –   The following are some examples of valid forms of photocopied personal identifications :    Drivers License State of Federally issued US or Foreign Passport Matricular Consular ID US Military ID Card Note: Student IDs, work IDs, birth certificates and Social Security cards are not accepted as valid identification.   4. Account Holder Signature I hereby swear or affirm that I have completed the foregoing, and the facts alleged are true, to the best of myknowledge and belief.SIGNED on this ________ day of ___________ , 20 ____ . Account Holder Signature:   ____________________________________   9 7 3 6 4 0 5 0 1 3 Jonathan Bracero(973)-460-5013(973)-460-5013 jonathan-bracero@mymail.berkeleycollege.edu159 barclay stPatersonNJ07503 H T CE V O 4 Gx x 8/21/2010 tried to calibrate. downtown , Paterson NJ Phone drop on the car floor,Screen was scratch. Another problem the phone doesn't hold charge for long, x
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