Product Insurance Claim
Product Insurance Claim
Policyholder Information
|
Name |
[Your Name] |
|
Contact Number |
(555) 123-4567 |
|
Policy Number |
987654321 |
Product Information
|
Product Name |
Samsung Galaxy S21 |
|
Model |
SM-G991U |
|
Serial Number |
1234567890 |
|
Purchase Date |
March 15, 2050 |
Incident Details
-
Date of Incident: July 10, 2050
-
Description: The phone was accidentally dropped from a height of 3 feet, resulting in a cracked screen and unresponsive touch functionality.
Evidence Submitted
-
Photos: Attached are images of the cracked screen and damaged phone.
-
Receipt: Copy of the purchase receipt from Best Buy.
-
Repair Estimate: Quote for screen replacement from a certified repair shop.
Claim Amount Requested
-
Amount: $250 (cost of screen repair)
Declaration and Signature
I certify that the information provided in this claim is accurate and complete.
[Your Name]
[Date]
