FSCA Submission Form

Kindly confirm the following information in order for us to proceed with your claim as soon as possible:

Claim Number*
Client First Name*
Client Last Name*
Client Phone Number*
You can add more than one number if needed.
Client Email Address*
Advisor Email Address*
Damage Report, Repair or Salvage?*
- Damage Report
- Repair
- Salvage
Device Make
Device Model
Colour
IMEI Number
This can be found on the back of the phone, or in Settings.
Damage / Problems Experienced / Notes
Risk Address*
Data Use Consent*
I have read, and agree to the conditions explained in the linked document, with regards to the use and protection of my data, in terms of the POPI act. Platinum Repairs have to comply with the new legislation and require your consent to process your data. Your data will be safe and will not be shared.
- Yes