Licensed Agent Photo

DO NOT UPLOAD OR FAX THIS PAGE

Only use the documents sent directly to you. These documents have individual markings that allow us to associate them with your claim. Make sure you have a *Valid Photo ID:

• Acceptable forms of photo ID: driver’s license, passport, federally issued ID card or matricula consular ID (ID must not be expired)

• Unacceptable forms of ID: student ID, work ID, birth certificate, Social Security card and expired photo IDs

• Name on the ID must match the name of the AT&T Account Holder and the name/signature on your submitted Sworn Affidavit & Proof of Loss Statement

• If the ID appears altered, forged, illegitimate or unreadable, we may not be able to proceed with your claim Documents must be clear

• Tips to make a clear photocopy of your photo ID: Use the enlarge, contrast/photo quality and color settings on your printer

• Color copies are preferred

Please return all documents and complete your claim within 60 days. After this period, your claim will be canceled and you may not be able to refile your claim.

Online (Recommended)

1 Print, fill out and sign the Sworn Affidavit & Proof of Loss Statement (found on page 2). 2 Scan or take pictures of both the completed affidavit and your valid photo ID. 3 Upload both documents at phoneclaim.com/att-uploader Fax

1 Print, fill out and sign the Sworn Affidavit & Proof of Loss Statement (found on page 2). 2 Photocopy your valid photo ID and write your AT&T wireless number on each page. 3 Fax both documents to 1-888-***-****.

Important Instructions:

Choose an option (Online or Fax) and follow the steps How to Submit the Required Documentation

Questions? Call us at 1-888-***-****.

AT&T Mobile Insurance, and the insurance component of AT&T Protect Advantage for 1, AT&T Protect Advantage for Business for 1, AT&T Protect Advantage for 4, and AT&T Protect Advantage for Business for 4 is underwritten by Continental Casualty Company, a CNA company (CNA), and administered by Asurion Protection Services, LLC (in Iowa, Lic. #100*******, in California, Asurion Protection Services Insurance Agency, LLC, CA Lic. #0D63161, in Puerto Rico, Asurion Protection Services of Puerto Rico, Inc.), a licensed agent of CNA. The person completing this document must be the AT&T Account Holder and must provide a copy of their valid photo ID*. Sworn Affidavit & Proof of Loss Statement

What device are you claiming? ALL FIELDS ARE REQUIRED. PLEASE PRINT USING BLUE OR BLACK INK. Account Holder information (for verification purposes only) Claim agreement

What happened to the device?

INSURANCE FRAUD IS A CRIME

For your protection, a person who knowingly presents a false or fraudulent insurance claim with the intent to injure, defraud, or deceive any insurer is guilty of a crime and may be subject to fines and confinement in prison. When fraud is discovered, Asurion takes appropriate steps to stop such fraud and explores all of its available legal remedies.

Full Name:

Contact Number: Alternate Contact Number:

Email Address:

Billing Address:

City: State: Zip Code:

I swear/affirm that the device I am claiming is owned by me and that the information provided above is true and accurate. I understand that knowingly presenting false or fraudulent information in support of this insurance claim with the intent to injure, defraud, or deceive any insurer is a crime. Asurion may take legal action, including reporting to law enforcement, when it suspects fraud in the presentation of insurance claims. Signature: Date:

My Device Is: Lost Stolen Damaged Malfunctioning

Date of Occurrence: Place of Occurrence:

Describe What Happened:

Manufacturer:

Wireless Number:

Model:

( Examples: iPhoneXR, GalaxyS10, V40, etc.)

( Examples: Apple, Samsung, LG, etc. )

Web: phoneclaim.com/att-uploader Fax: 1-888-***-**** Control # COV53058 Rev 28 EDT:11/1/07 RDT: 10/22/2019 Asurion Attn: Review Team P.O. Box 413886 Kansas City, MO 64141-3886 The person completing this document must be the AT&T Account Holder and must provide a copy of their valid photo ID*. Note: If your device was damaged or malfunctioning, you are required to return it to Asurion upon receipt of your replacement.

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