Sworn Affidavit & Proof of Loss Statement

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

What device are you claiming? ALL FIELDS ARE REQUIRED. PLEASE PRINT USING BLUE OR BLACK INK

fl Si H ) Wireless Number: (j 6
Claim ID: X % V (J 6
f f L t Model: | 6
Manufacturer:
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ESN/MEID/IMEI:
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What happened to the device?

My Device Is: Lost Stolen (X Damaged Malfunctioning

Date of Occurrence: L9' Place of Occurrence: K'-V k

Describe What Happened: ff^f® FWfl RlUlT iWTtyfrO

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Account Owner/Account Manager information

Full Name: W ukJ B' 1W o

Primary Phone: MV 4 ’S I Alternate Phone: A 13'T 6'

Email Address: 0 0* U«V>VU P MI

Billing Address: ll(WI t' M0

City:................ fa ')............ '..................................................................... State:...... ]\j ]............... Zip Code:.../])0V3

Claim agreement

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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.

Signature:......... Date:

asurion phQDeclaim.com/verizon-uploader