Acknowledgement Form

I, *, certify that:

My device was fully functional (free of any defects and damages) at the time I purchased my protection plan

I am filing a claim on the device covered by my protection plan (not on a non covered device)

I have not used my device for commercial/public purposes

I have not misrepresented any information during this claim process

I understand that filing misrepresented claims may lead to civil or criminal prosecution

By entering my Full Name below, I declare that the foregoing is true and correct

You must acknowledge all statements to proceed.

Signed by: (Please enter your first and last name) *

Required.

Email Address: *

Please enter a valid email address.

Note that if you would like a copy of this form, you must print this page before submitting.

Claim Number: