Licensed Agent Cna

DO NOT UPLOAD/FAX THIS PAGE

The document 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, federally issued ID card or matricula consular ID

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

• Name on the ID must match name of the Sprint account holder / authorized user who completes the Sworn Affidavit & Proof of Loss Statement

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

• The ID cannot be expired. If the ID appears altered, forged, illegitimate or unreadable, we may 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

• Black and white copies are preferred

Return all documents within 60 days from the date you filed your claim or your claim may be denied Online (Recommended)

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

2 Have the affidavit notarized.

3 Scan or digitally photograph the affidavit, proof of ownership, and your valid photo ID. Acceptable forms of photo ID: valid driver’s license, passport, federally issued ID card or matricula consular ID. 4 Upload both documents at phoneclaim.com/sprint-uploader Fax

1 Print, fill out and sign the Sworn Affidavit & Proof of Loss Statement. 2 Photocopy proof of ownership and photo ID and handwrite your wireless number on each paper. 3 Fax both documents to 1-866-***-****.

Tips to speed up your claim

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

Questions? Get answers at phoneclaim.com/sprint. Or call us at 1-800-***-****. The Equipment Replacement Program is underwritten by Continental Casualty Company, a CNA company (CNA) and administered by Asurion Protection Services, LLC, a licensed agent of CNA

(In California, Asurion Protection Services Insurance Agency, LLC, CA Lic. #OD63161. In Puerto Rico, Asurion Protection Services of Puerto Rico, Inc.)

• Screenshot from iTunes account (if Apple product) – must show ESN/MEID/IMEI of device being claimed Log into iTunes account > Preferences > Devices > Hover cursor over model name

• Screenshot from Google account (if Android product) – Log in to google.com/dashboard > Click the Android section to display ESN/MEID/IMEI

• Store Receipt – must be an electronic register or ownership receipt with ESN/MEID/IMEI and make/model of device

• Back of Device – ESN/MEID/IMEI being claimed must be clearly visible (battery may need to be removed)

• Service Agreement – must show the make, model and ESN/MEID/IMEI of device being claimed

• UPC Code from Box – must show ESN/MEID/IMEI of device being claimed

• Packing Slip – must show the contents of shipment for device and ESN/MEID/IMEI being claimed How to Locate Proof of Ownership

Sworn Affidavit & Proof of Loss Statement Page 1 of 2 What device are you claiming? ALL FIELDS ARE REQUIRED. PLEASE PRINT USING BLUE OR BLACK INK Account holder / authorized user information

Full Name:

Contact Number: Alternate Contact Number:

Email Address:

Billing Address:

City: State: Zip Code:

Driver’s license number (if valid): Date of Birth: State: Expiration Date:

Manufacturer:

Wireless Number:

Model:

( Examples: iPhone6, GalaxyS6, G3, etc.)

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

Web: phoneclaim.com/sprint-uploader Fax: 1-866-***-**** Asurion Attn: Review Team P.O. Box 413886 Kansas City, MO 64141-3886 Control # F-017-67-SEN-ACR Rev 04 EDT:10/10/13 RDT: 03/11/16 Continued on next page

THIS DOCUMENT MUST BE COMPLETED BY THE ACCOUNT HOLDER / AUTHORIZED USER ON YOUR SPRINT ACCOUNT. THE PERSON COMPLETING THE DOCUMENT MUST ALSO PROVIDE A PHOTOCOPY OF THEIR VALID PHOTO ID. 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.

( This is the number of the device for which you are filing the claim ) Sworn Affidavit & Proof of Loss Statement Page 2 of 2 Claim agreement and notarization (This section must be signed, notarized and sealed by a notary public) I swear/affirm that the device I am claiming is owned/leased 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. Verify your wireless device number:

Signed on this day of, 20

Signature:

Before me, the undersigned authority, personally appeared, who is: Personally known to me. OR Presented as identification, and who being duly sworn, stated under oath that he/she executed the foregoing for the purposes therein intended, this day of, 20 Notary public signature:

STATE of COUNTRY of

My commission expires: (SEAL)

Web: phoneclaim.com/sprint-uploader Fax: 1-866-***-**** Asurion Attn: Review Team P.O. Box 413886 Kansas City, MO 64141-3886 Control # F-017-67-SEN-ACR Rev 04 EDT:10/10/13 RDT: 03/11/16 What happened to the device?

My Device Is: Lost Stolen Damaged Malfunctioning

Date of Occurrence:

Place of Occurrence:

Describe in Detail What Happened to your Device:

ALL FIELDS ARE REQUIRED. PLEASE PRINT USING BLUE OR BLACK INK 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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