The person completing this document must be the AT&T Account Holder and must provide a copy of their

valid photo ID'.

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

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( Examples: Apple, Samsung, LG, etc. )

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(Examples: iPhoneXR, GalaxyS10, V40, etc.)

What happened to the device?

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Note: If your device was damaged or malfunctioning, you are required 10 return it 10 Asurion upon receipt of your replacement.

Account Holder information (for verification purposes only)

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Claim agreement

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