Affidavit for Reimbursement

I filed a claim  .

I declare as follows:

• I am the account holder for this claim, or the account holder’s authorized representative.
• A Protection Plan was purchased to cover the item in question, either by me or by someone who transferred the ownership of the covered item and the Protection Plan to me.
• I have read and understand the terms and conditions of my Protection Plan which were provided to me or otherwise made available to me.
• The covered item in question is not functional and, to the best of my knowledge, is eligible for coverage under the terms and conditions of my Protection Plan.
• I understand that I will be reimbursed directly for the replacement of the covered item based on the information I provided during the claims process and this affidavit.

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

Date:  

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