Protection Program Claim Form

Protection Program Claim Form

Please complete all fields of this form to submit your claim. You will receive a follow up confirming the claim was successfully filed and then hear from our team regarding the next steps to handle your repairs/replacements.
Payout amount/claims cost:
Repair vs replace:

RepairReplace
Date of payout/replacement ordered:

MonthDayYear
Date
Source of replacement / repair provider:
Amazon, Backmarket, etc
Partner or Group ID*
If this is not filled out automatically, refer to coverage confirmation "Organization ID" or enter your business/organization's name.
Your email address*
Please provide the email address associated with your plan/account if applicable.
Your cell phone number*
Provide the cell phone number that is registered to your plan/account if applicable.
Your address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please Indicate what items were affected and what happened to them. If multiple items were affected, click the "+ Add another item" button to add more entries.*
When were these items affected?

MonthDayYear
(Please note, all items you submit on this claim must have been affected as part of the same incident, if multiple items were affected by a loss during separate incidents, file 1 claim per incident)

Provide incident information and documentation
Please explain how this incident occurred and as many details as possible regarding events leading up to it.*
IMPORTANT: Phone Damage Verification Video Instructions:

Refer to training materials for a demo. Take a continuous video performing the following actions:

1. Show the Serial Number and IMEI on the phone's "about" page within settings.
2. Touch the screen and scroll up and down.
3. Flip the device over so the back-side is also visible.

Ensure the video is very clear and do not move the phone too quickly.
Upload proof of loss. For DAMAGE or MALFUNCTIONS: Include photos/videos showing the damages and issues with your items -- THEFT or VANDALISM: You must provide a copy of a filed police report outlining the incident and the information of your affected items. *

Cancelof
Upload copies of the receipts for your affected items. (Optional)

Cancelof

Submit your claim
Preferred email address for receiving claim communications*
Be sure to use an email address which you will have access to for our team to reach you.
Preferred phone number for receiving claim communications*
Be sure to use a phone number our team will be able to reach you at.
Please provide your full legal name*

First NameLast Name
We must advise you that any person who knowingly, and with intent to commit fraud, files a statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact thereto, commits a fraudulent act, which is a crime and may be prosecuted to the full extent of the law. By signing and submitting this claim, I agree that the statements above are true and correct to the best of my knowledge and cannot be changed once submitted to the company.

Clear
Please verify that you are human*
Should be Empty:

Provide incident information and documentation