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Insurance Driver

Angier, NC
November 28, 2018

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*** **** ********** ****

Suite ***

Wayne, PA ***87-1631


Claim Number: 25113952 Mobile Device Number: 1-908-***-**** Date of Incident: 08/18/2015 Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claims containing any materially false information or conceals, for the purposes of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and may subject such person to criminal and substantial civil penalties. Instructions: (Filling out this form completely will result in faster processing of your claim.) 1. Please REVIEW and VERIFY all information for accuracy, fill in any blank information and make any necessary corrections. 2. Please provide your email address below; this will allow us to send you automatic updates regarding your claim. Your email address will be kept confidential and we will not share with any third party entities. 3. Complete the Detailed Description of What Happened to Your Mobile Device section 4. The Accountholder (Insured) must sign this form and provide his/her driver's license/government ID number and state of issue. 5. Please fax the completed form to Assurant Solutions at 1-866-***-**** or mail to the above address. Accountholder's (Insured)

Name: JACOB MALLOY Claimant's Name: Jacob Malloy

Street Address: 251 S HARRISON ST

City, State, Zip: EAST ORANGE, NJ 07018-1470

Email Address:

Equipment Being Claimed: (If unknown, please contact T-Mobile) Manufacturer: ALCATEL Model:


BLUE 9006W TMO Serial Number (ESN/MEID): 014************ Detailed Description of What Happened To Your Device (How and Where was your device LOST, DAMAGED, or STOLEN): The policy provides that the Accountholder (Insured) shall, as soon as practical, report to this company or its agent every incident which may become a claim under this policy and shall also file, with the Company or its agent within 90 days (unless otherwise required by state law) from the date of incident, a detailed Sworn Proof of Loss. Failure by the Accountholder (Insured) to report the said incident and to file such Sworn Proof of Loss, as herein before provided, shall invalidate any claim under this policy for such incident. Any person who knowingly and with intent to defraud or deceive an insurance company, files a Sworn Proof of Loss containing any false, incomplete or misleading information, or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. The Signal and the insurance company will take all available actions against anyone who commits insurance fraud. I declare that the above information and statements made by me on this Sworn Proof of Loss are accurate and truthful to the best of my knowledge. I make this declaration intending it to have the same status in law as if it had been made under oath or affirmed. Accountholder (Insured) - Print Name Driver's License or Government Issued Photo ID Number X

Accountholder (Insured) - Signature State where Driver's License or Government ID was Issued Please fax this completed form to 1-866-***-****.

To check the status of your claim 24 hours a day please visit or call 1-866-***-****. WP00428R-0614

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