Cellular Telephone Claim Form WARNING: INSURANCE FRAUD IS A CRIME POLICY NO 1. GENERAL Title First Name Surname ID Number Bank Account No. Marital Status Date of Birth Tel No. (W) Cell No. Email Address* Address City 2. CELLULAR TELEPHONE Make Model Serial No. EMI No. Service provider Date of Purchase Cell No. 3. DAMAGE/LOSS TO CELLULAR TELEPHONE Date of Damage Full description 4. DESCRIPTION (only applicable if stolen) Address where loss occurred Has the line been cancelled? Yes No Was cellphone switched on at the time of loss? Yes No Was sim card in cellphone at the time of loss? Yes No Have you applied for a new sim card? Yes No Is there a hire Purchase Agreement on Cellphone Yes No From whom Account No. Name of Company Outstanding Balance $ Period Was loss reported to the Z.R.P. Yes No Name of Police Station where loss Reported Z.R.P. Ref No. Estimated value for replacement $ Have you already replaced the cellphone? Yes No Where Are you the sole owner of the cellphone? Yes No If NO, further details I/We warrant the truth of the answers to the above questions and I/We declare that no information has been withheld and that the amount claimed represents my/our loss arising from the above stated occurrence. THE ISSUE OF THIS FORM IS NOT ADMISSION OF LIABILITY I hereby certify that the information in this claim form is true and correct to the best of my knowledge and belief. I authorize Champions Insurance Company to process the claim based on the information provided.