Please supply the blacklisting form that was submitted to the service provider (as proof of cancellation of the line)

Declaration

I/We warrant the truth of the answers to the questions below and I/we declare that no information has been withheld and that the amount claimed represents my/our loss arising from the stated occurrence. By submitting this claim I declare herewith that I am the Insured in terms of this policy.

[* Indicates required fields]

Policy Number:
Insured's lastname and initials, or company name:*
Insured's e-mail address:
Phone number - Home:
Phone number - Work:
Cellphone number:
Identity Number:
Address line 1:
Address line 2:
Address line 3:
City:
Province:
Postal code:
Occupation:
Cellphone Make:
Model:
Serial/EMI No:
Contract With:



Service Provider:
Date Acquired:
Cellphone number:
Damaged Cellphone & Accessories
Date of incident:
Please Describe fully how the damage occurred:
Stolen / Lost Cellphone & Accessories (eg. pouch)
Date of loss/theft:
Please describe fully how the loss occurred:
At what location did the loss occur?
Address line 1:
Address line 2:
Address line 3:
City:
Province:
Postal code:
Has the line been cancelled?


If yes, date:
Was the cellphone switched on during the loss?


Was the simcard in the phone during the loss?


Have you already applied for a new simcard?


If yes, date:
Is the cellphone being paid off?


If yes, with whom?
Account Number:
Outstanding amount owing:
Duration of payment agreement:
Has the theft been reported to the SAP?


If yes, date:
If no, please give reason:
SAP Office where report was made and to whom (name):
SAP Reference Number:
Have you already replaced your cellphone?


If yes, from where was it bought?
Amount Paid:
Are you the sole owner of the cellphone?


If no, please provide details:
I hereby certify that the above information is correct.*

I hereby certify that I agree to the Declaration.*


Copyright © 2012 • Snyman Van der Vyver | All rights reserved