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NSSI

Claim Forms and Sworn Statement

State:
I,

IL

County:

United States of America

Jake Drouillard

affirm that:

1. I am a policyholder under policy number

2013

0009

4634

30 North Brainard St
(734)652-4368 4. Email: jakedrouillard@aol.com
3. Phone:
5. Date of Incident 1 / 07 / 20146. Location: North Central College
7. Type of Claim: [X] Damage [ ] Theft [ ] Fire [ ] Power Surge [ ] Other
8. Description of Incident: Opened up ipad case to use and screen was pixalated and
2. My current address is:

the color red was present throughout when it shouldn't be. Unsure what caused
it to break.
___
9. Do you have secondary property insurance? ( YES or (___)
NO )
a. Name of insurance company:

____

b. Have they been notified of the incident? ( YES or(____


NO )
c. Payment received from secondary insurance? $

___

10. Did you notify the police? ( YES or (___


NO )) (Required for Theft, Vandalism and Fire ONLY)
a. Department and Location:
b. Officer and Case Number:
c. Police Department Contact Number:
11. Who should claim payment be remitted to?

Jake Drouillard
Address: 30 North Brainard Street Student Postal # 1175
Name:

City, State Zip Code:

Naperville, IL 60540

National Student Services, Inc. may require from the policyholder an assignment of all rights of recovery against any party for loss to the extent that
payment therefore is made by this company. Do not dispose of any damaged items until your claim has been settled.
We must advise you that any person who knowingly and with intent to defraud any insurance company files a statement of claim containing any
materially false information, or conceals for the purpose of misleading information concerning any fact thereto, commits a fraudulent insurance act,
which is a crime.
By signing, I agree that the statements above are true and correct to the best of my knowledge and cannot be changed once submitted to the
company. All payments will be remitted to the person listed above.

Policyholder:

Jake Drouillard
Print Name
Signature

PERSONAL PROPERTY INVENTORY FORM


Please provide a detailed description of all items pertaining to the incident.
Concealment or Fraud: WE DO NOT PROVIDE COVERAGE FOR ANY INSURED WHO
HAS INTENTIONALLY CONCEALED OR MISREPRESENTED ANY MATERIAL FACT
OR CIRCUMSTANCES RELATING TO THIS INSURANCE.
Item Description
(list each item separately)

Qty

Purchase
Date/Location

Purchase
Price

(Please print additional pages as needed.)

For Adjustor Use Only


RC

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Electronic Device Checklist


(FOR ELECTRONIC DEVICE CLAIMS ONLY)
Form MUST be completed in its entirety.
All repair estimates must have prior approval from an adjustor to be considered for a claim payment.
Estimates that were not given prior approval will be null and void.

DEVICE SPECIFICATIONS:
Device Serial #:

DN6G4MRHDKPJ

White

Device Color:

Apple
Device Model: Ipad 2nd Generation
___
Device Type: Laptop / (__)
iPad / Tablet / iPhone / Cell Phone / E-reader / Game Console / iPod / Camera (circle)
Device Make:

CPU Type (Pentium, Celeron, AMD):


Monitor/Screen Size:
Hard Drive Size (GB):

1 GHz dual-core ARM Cortex-A9

9.7 inches Diagonal


32GB

Speed (GHz):
RAM (GB):

1GHz

Undisclosed by Apple

DAMAGE:
Broken Screen
Broken Casing (bottom or top)
Hardware (ports, trackpads, keyboard, home button, etc.)
Liquid Damage

Other (please specify): Unsure

Additional Comments:

if issue is screen or other

As stated above, image is pixilated and discolored cause is

unknown, maybe, screen damage, internal damage to hardware,or software issues

the latter two seem more likely due to the appearance.

SEND FORMS ATTN:


NSSI
P.O. Box 2137
Stillwater, OK 74076
toll-free: 800.256.6774
fax: 405.334.5418
email: claims@nssi.com