Member #:________________________________________________ Return Guarantee Protection Claim Form

Daytime Phone #: __________________________________________

Member Name:____________________________________________
Date:
Member Address: __________________________________________

____________________________________________________
How to file a claim:
1. Please refer to your membership materials or visit www.buyersadvantage.com for terms and conditions and restrictions before
making a Return Guarantee Protection claim.
2. Within 90 days of purchase, return the item along with this completed Return Guarantee Protection Claim Form, original dated
sales receipt, and the manufacturer’s written warranty (if applicable) to: Buyers Advantage, Return Department, 300 W.
Schrock Road, Westerville, OH 43081-2873. Insuring the package is suggested.
3. A refund check for the returned item will be sent directly to you within 30 days of receipt of all necessary information. You
must send the item to Buyers Advantage® before any claim will be paid. You are responsible for any and all mailing costs,
including insurance. We may request further documentation from you. The returned item becomes the property of Buyers
Advantage and will not be returned to you. If payment is made under the Buyers Advantage Return Guarantee, Buyers
Advantage is entitled to recover such amounts from other parties or persons. Any party or person to or for whom Buyers
Advantage makes payment must transfer to Buyers Advantage his or her rights to recovery against any other party or person.
You must do everything necessary to secure these rights and must do nothing that would jeopardize them, or these rights will be
recovered from you.

**REQUIRED INFORMATION**
Product _____________________________ Original Purchase Date _______________________________________

Manufacturer ________________________ Reason for Return ___________________________________________

Model ______________________________ Original Purchase Price ______________________________________

excludes tax, shipping and handling

I understand that this claim form must be accurately completed and that all required documentation must be submitted before
any claim under this service can be processed or paid. I authorize Claims Administration to obtain from me a statement if
needed to process my claim. In addition, I understand that any claim may be denied if I fail to return this form within 90
days of purchase. If my claim is not in accordance with the program’s provisions as outlined in my Buyers Advantage
membership kit, I understand that my product can be returned to me at my expense within 5 days of receipt.

Signature _____________________________ Date ___________________________________

**PLEASE SUBMIT ALL OF THE FOLLOWING DOCUMENTATION FOR REVIEW**

Please place documentation inside package
❑ Completed Return Guarantee Protection Claim Form

❑ Item (with manufacturer’s written warranty if applicable)

❑ Original purchase receipt

❑ If mail order purchase, include packing slip as proof-of-delivery

**FOR OFFICE USE ONLY**

Rebate Code _________________ Processing Date ___________________________

Total $ Amount ______________ Join Date _________________________________

Status Code __________________ YTD Total ________________________________

Adjuster’s Initials _________________ Supervisor’s Initials _________________________

Comments ____________________________________________________________________________
© 2003, Trilegiant Corporation BGNRTNFM88
Buyers Advantage Return Department ◆ 300 West Schrock Road ◆ Westerville, OH 43081-2873
www.buyersadvantage.com