Your Information
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email Address
*
Email used to register
Address
*
Street Address
Street Address Line 2
City
Please Select
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State
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Store Information
Tell us where you purchased your cellhelmet product
Store Name
*
Store Name
Store Address
*
Store Address
Store Address Line 2
Store City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Store State
Store Zip
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Device Information
Device Name
*
Device Model
*
Policy PIN
*
PIN code used to register the Device
IMEI Number
*
Date of the Incident
*
-
Month
-
Day
Year
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Description of Incident
*
Attatchment
*
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Please attach an image clearly showing the damage of your device and how it happened. Be sure to have the device IMEI or cellhelmet Registration app on display for the image. see examples...
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Confirmation
*
I confirm that my phone is NOT lost, stolen, or damaged due to water.
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