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
Declaration and Signature
I certify that the information provided in this claim is accurate and complete.
[Your Name]
[Date]
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