Account Manager Photo

DO NOT FAX THIS PAGE

The Sworn Affidavit & Proof of Loss Statement is marked with a barcode that is specific to your claim. Using a photocopy with an incorrect barcode will delay your claim. Make sure you have a valid photo ID.

• Acceptable forms of photo ID: valid driver’s license, passport, State DMV-issued ID card or matricula consular ID. ID must not be expired

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

• Name on the ID must match name of the Account Owner who completes and signs the Sworn Affidavit & Proof of Loss Statement

• If name does not match, then you may need to provide additional documentation

• If the ID appears altered, forged, illegitimate or unreadable, we will not be able to proceed with your claim Make sure all document scans or faxes are clear and easy to read

• When making the photocopy of your photo ID, consider using the enlarge and contrast settings to make the ID easier to read

• Color copies are preferred

Online (Recommended)

1 Print, fill out and sign the Sworn Affidavit & Proof of Loss Statement. Found on page 2 of this document.

2 Scan or take pictures of both the completed Sworn Affidavit & Proof of Loss Statement and your valid photo ID. Acceptable forms of photo ID: valid driver’s license, passport, State DMV-issued ID card or matricula consular ID. 3 Upload both documents at phoneclaim.com/verizon-uploader Fax

1 Print, fill out and sign the Sworn Affidavit & Proof of Loss Statement. 2 Photocopy your valid photo ID and write your Verizon Wireless number on each page. 3 Fax both documents to 1-877-***-****.

How to prevent delays in processing your claim

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

• Log in to google.com/dashboard

• Click the Android section to display

ESN/MEID/IMEI

For Apple products: For Android products: For most devices: Find this information on:

• Back of the phone/device or under the battery

(not all batteries are accessible)

• Your Customer Agreement (available at verizonwireless.com)

• The box the phone/device came in

• If none of these are available please contact Verizon Wireless Verizon’s device protection program includes Wireless Phone Protection (WPP), which is insurance coverage underwritten by Liberty Insurance Underwriters Inc. (New York, NY) or one of its insurance company affiliates. Asurion Insurance Services, Inc. (in California, Agent License #0B35141; in Iowa, Agent License #100*******) is the agent and provides the claims servicing under this insurance program. How to find your device manufacturer, model and ESN/MEID/IMEI

• Open iTunes

• Choose iTunes > Preferences in Mac OS X

• Choose Edit > Preferences in Windows

• Click the Devices tab

• Position the mouse over “Backup Device”

to display ESN/MEID/IMEI

The person completing this document must be a Verizon Account Manager/Authorized user and must provide a copy of their vaild photo ID. Please return all documents and complete your claim within 180 days. After this period, your claim will be canceled and you may not be able to refile your claim. Questions? Call us at 1-888-***-****.

Sworn Affidavit & Proof of Loss Statement

What device are you claiming? ALL FIELDS ARE REQUIRED. PLEASE PRINT USING BLUE OR BLACK INK Account Owner information

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:

ESN/MEID/IMEI:

Wireless Number:

Model:

( Examples: Samsung, LG, ZTE, etc. ) ( Examples: iPhone X, Galaxy S8+, Moto Z3, etc.)

( Refer to the instructions on the previous page ) Web: phoneclaim.com/verizon-uploader Fax: 1-877-***-**** Control # COV53561 Rev 1 RDATE: 05/2020 Asurion Attn: Review Team P.O. Box 413886 Kansas City, MO 64141-3886 The person completing this document must be a Verizon Account Manager/Authorized user and must provide a copy of their vaild photo ID. Note: If your device was damaged or malfunctioning, you are required to return it to Asurion upon receipt of your replacement. I hereby make an insurance claim against the insurance company as shown on this insurance claim affidavit. I acknowledge that if any property which is the subject of this claim and which is replaced or paid for by the insurer is recovered at any time, it is the property of the insurance company and must be returned to the insurance company. I understand that if I fail to return such property, I am subject to, and authorize a non-return fee of up to $300 to be charged under the insurance policy using the method of payment used to originally file this claim.

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