Sworn Affidavit & Proof of Loss Statement

THIS DOCUMENT MUST BE COMPLETED BY AN ACCOUNT OWNERIACCOUNT MANAGER ON YOUR VERIZON WIBELESS ACCOUNT
THE PERSON COMPLETING THE DOCUMENT MUST ALSO PROVIDE A PHOTO COPY OF THEIR VALID PHOTO ID.

INSURANCE FRAUD IS A CRIME

For your protection, a person who knowingly presents a false or fraudulent insurance claim with
the intent to injure, defraud, or deceive any insurer is guilty of a crime and may be subject to
fines and confinement in prison. When fraud is discovered, Asurion takes appropriate steps to
stop such fraud and explores all of its available legal remedies.

What device are you claiming? ALL FIELDSARE HEOUIRED. PLEASE PRINT USING BLUE OR BLACK lNK

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Manufacturer: * FP L e Moder: I p h o A e O Tp L VS
( Exmples Apple. Samsung, iVci.orola. elc. ) I Exampls:iPhcne6, GalaB/S6. DRCIDN4A)C(, ctc )

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What happened to the device?

ls: Lost Stolen Y Damaged

My Device

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Account OwnerlAccount Manager information

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Full Name:
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Primary Phone: Ahdrnale Phone:

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EmairAddress: m tu1 ' 4)u<- {-- L{--72 2 Vahn L,np4 rLlyf ,r4 1<{ E 7^u;
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Claim agreement

i hereby make an insurance claim against the insurance company as shown on this insurance claim affidavii. 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 musi be returned to the insurance
6ompany. I understand lhat i{ I fail to return such prGperty, I am subiecl to, and authorize a non-return fee of up to 5300 to be charged under the insurance policy using
lhe method of payment used to originally file this claim.

I awear/aftirm thal the device I am claiming is owned by me and that the information provided above is true and accurate. I understand that knowingly presenting .
lalse or iraudulent information in support ol this insurane claim with the intst to iniure, delraud, or deceive any insurer is a crime. Asurion may takc krg t '
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astion, including reportingto law eniorcement, whgr'lFuspectslraud in the presentation ot insurance claims. I , n-, Ib

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