Sworn Affidavit& Proof of Loss Statement

The personcompleting this document must be a VerizonAccount Manager/Authorizeduser and must provide a copy of their vaild photo 10.

What device are you claiming?

Wireless Number: ~DJ[!J-[fJ[iI.4]-[I]~~liJ

Manufacturer: I5 1~~lSJrU]Wl~]JLJDI J ~lmlbJ[ill00GJ[JJ~J[11D
( Examples: Samsung,LG, ZfE, etc. )
Model:
( Examples: iPhone X, Galaxy 88+, Molo Z3, eto.)

ESN/MEIDIIMEI: LJDDDDDDDDUDDI ICJDDDDDDDDD

cerv~~struc;:;;;;rei~~g;) IJ'VMl? ('J!, ft:ev/t?vs (.7 JVffld f.4tJJd ,I/If ~ fJt>
What happened to the device?

My Device Is: OLost 0 Stolen ~amaged 0 Malfunctioning

Date of occurrenc) .dl/..JJ:L 2tJ ~ Place of Occurrence: J1L_IJJ:2=e=K.....
' _
Describe What Happened: -iZd f>t>e LI4l~&('
''''1_l.:r1 Pelc Itlfi- _

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

Account Owner information

Full Name: }dJ§J:,{/.t e I.. 4 K1L~~~ _

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Contact Number: ....::Q)'--'--'--~.I..'----Zf.R.
2't,L/Q Alternate Contact Number: _

EmailAddress: 1Jt/</1" t41?p!' if it/I) 4L d..I::J~L",,--- . .

Billing Address: _ C/6 __ ...§~~.~ 1IvII hi l~ __ f[ l_ptA ' tflL':._!?) __. .__
, .__,__
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City: ~_teR~..t....J! State: __ y 14 Zip Code: tJ ~ ;; G 5
Claim agreement

I hereby make an insurance claim against the insurance company as shown on this insurance claim affidavit. 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 of the insurance company and must be returned to the insurance
company. I understand that if I fail to return such property, I am suolecr to, and authorize a non-return fee of up to $300 to be charged under the insurance policy using
the method of payment used to originally file this claim.

Iswear/affirm that the device Iam claiming is owned by me and that the information provided above is true and accurate. Iunderstand that knowingly presenting
false or fraudulent information in support of this insurance claim with the intent to injure, defraud, or deceive any insurer is a crime. Asurion may take legal
action, including reporting to law enforcement, when it suspects fraud in the presentation of insurance claims.

Signalure, 1!iJ.I~~ Daten.Mw tp~

•
Control # COV53561 Rev 1 RDATE: 05/2020
osunon Web: pbonerJaim cQmlyeri70n~rlp!oador Fax' 1-877,595-1399
Asunon Attn. PeYie'lv Team p.o 80x 41~~886,<ansas Cltv MO 641...11·386'"'