Sworn Affidavit & Proof of Loss Statement

THIS DOCUMENT MUST BE COMPLETED BY AN ACCOUNT OWNER/ACCOUNT MANAGER ON YOUR VERIZON WIRELESS ACCOUNT
THE PERSON COMPLETING THE DOCUMENT MUST ALSO PROVIDE A PHOTO COPY OF THEIR VALID PHOTO ID.

What device are you claiming? ALL FIELEARE REOI'IRED. HfASE PRNT USNG BLUE OR BLACT INK

Lq L Wireless Number:
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Manufacturer: A FP L G Moder: Ip h o A € ]Tp L,V.S
1 Exmples; Apple, Sarnsung, ivoltrola, etc. ) ( Examples: iPhse6, Gdaiys6. DRCIDNIAIX, etc )

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( Fefer to the instructrons or r
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What happend to the device?

Account Owner/Account Managa inlormation

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Full Name:

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C*alm agrearent

J hereby make an lnsurance claim against the insurance company as shown on this insurance claim affidavii. I acknowledge that if any property which is the subject of
this claim and which is replaced or paid for by the insurer is recovered at any time, it is the property 01 the insurance company and must be r€turned to the insurance
company. I understand that i{ I fail to return such property. I am subiecl to, and authorize a non-return fee of up to 5300 to be charged under the insurance policy u6ing
ihe method of payment used to originally file this claim.

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