Electronic Extended Warranty Claim

Customer Name and Phone Number

Customers Name

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Customer Home Phone

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Customer Alt Phone

Email Address

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Customer's Address

Customer Address

Customer Address 2

City

State

Zip Code

Claim Information

Account Number (if available)

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Invoice Number (if available)

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Serial Number (if available)

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When did Problem Start?

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Description

What is Affected? TV Components/Home Theater Equipment Vacuums Exercise Equipment Computer Cameras

Please tell us what is affected.

What is wrong with the TV? No Power Lines on Screen No Sound Pixels Blurry Picture No Picture Turns off and on by itself Other

Please tell us what is wrong with the TV.

Explain what is wrong?

Please be specific about what is wrong

What is wrong with the Component? No Power No Sound Noisy Other

Please tell us what is wrong with the Component.

Explain what is wrong?

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What is wrong with the Vacuum? No Power No Suction Noisy Other

Please tell us what is wrong with the Vacuum.

Explain what is wrong?

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What is wrong with the Exercise Equipment? Noisy Belt Issues Other

Please tell us what is wrong with the TV.

Explain what is wrong?

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What is wrong with the Computer? Bad Mother Board No Power Other

Please tell us what is wrong with the Computer.

Explain what is wrong?

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What is wrong with the Camera? No Power Lens Issues Zoom Issues Other

Please tell us what is wrong with the TV.

Explain what is wrong?

Please be specific about what is wrong

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