Sworn Affidavit & Proof of Loss Statement

ACCOU NT.
THIS DOCUMENT MUST BE COMPLETED BY AN ACCOUNT OWNER/ACCOUNT MANAGER ON YOUR VERI ZON WIRELESS
THE PERSON COMPLETI NG THE DOCUMENT MUST ALSO PROVIDE A PHOTO COPY OF THEIR VALID PHOTO ID.

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What device are you claiming? ALL FIELDS ARE REQUIRED. PLEASE PRINT USING BLUE OR BLACK INK

Claim ID:
4 s ~~4 Dfu~ 3 Wireless Number:
'7 D 7 lo39. -0 3 s,
Manufacturer:
SCL\Y \S ~r\3 Model: c; C\_ l ll K. '/ S8 t .ir· i
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ESN/MEID/IMEI:
357Y 9Z08 O2'~ 833C f
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What happened to the device?

My Device Is: Lost Stolen 'j..E_amaged ')(.Malfunctioning

Date o1 Occurrence:4 -1-~ D -It- \r') DV'<\ e

Place of Occurrence :

Describe What Happened: Q~t) n~ ~c r-f-e(\ \ovtk e ~ Vf') ~ 0 ~ fh-e. phone

stil\ worKe d ur,t, l ~k)D 1-:I: woke. l).P a ~d pr\on-e hQcf
blac.K Ser~ eV\,
Account Owner/Account Manager information

Full Name: aa rt Q_ Mi cks

Primary Phone: L101) {£,8'{- D3 5 7 Alternate Phone: NI A
EmailAddress: u.ii bdc.r-l~ ~ca, ~t, net

Billing Address: i OI O S'" Soda ted,

city: '3() oka r\ e.. State: WA Zip Code: ~,a~\/.

Claim agreement

that ,t any proµerty which 1.s lhe subjGct ol

I i'cr2by r,,a~e arr •r,!>uran~,, cla,m aga,nsi !tie ,nsurance company as sllown on ttHs insurance claim aif1dnv1t I ack11owleclge
company and must IJe ret urned to tne insurance
th,s claim ard N~"ch 1s r;c,placed or paid for by the 1ns~rer 1s recovered ;it any time , 111•; the propertv of the insurance
S'.JOO 10 be charged uncle• the insurance policy using
c-,moar;y I ur.d,;,rsland :h~t ,1 I la,110 return such p•ope rty. I am suh1ect lo. and ilulhcm!e a non-return lee of up to
;n,; mclr.od c,; payrr'?nl used !o ong1nally file t~us claim
and accurate. I understand that knowingly presenting
I swear/alllrm that the d evice I am claiming is owned by me and !hat the information provided above is true
any insurer is a crime. Asurio n may take legal
ac tion, 1ncludmg reporung to law enforcement. when it sus,s;cts fr:d
t;;fse or fraudulent information in support of this Insurance claim with the intent to injure , defraud, or deceive
in the presentallon or insurance claims.

S1gnatu1e; fJa✓tl!a "'~ik,,e,,~ ] Date : 'i-- 3 - ao

pb,QQOOaim com{verizoo-11oloader
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