Lateral Unison Insurance Brokers Claim Submission Insurance Claim Form (LUIB) Kindly confirm the following information in order for us to proceed with your claim as soon as possible: Claim #First Name*Last Name*Phone NumberYou can add more than one number if needed.Email Address Type Of Device* Cellphone Tablet Smart Watch TV Laptop PC Other MacBook or Other?* MacBook Other This field is hidden when viewing the formWill you need a loan device?Please note that this is subject to availability of our loan devices. Since they are in high demand, we work on a “first come, first serve” basis. If the device has to be couriered, it will be sent to the same address from where your device is collected. Yes No Please read through the Loan Phone Agreement, and fill in the following fields. A copy of this agreement will be emailed to you.This field is hidden when viewing the formAgreement on loan device*I have read and understood the Loan Device Agreement. Yes This field is hidden when viewing the formDo you want insurance on the loan device?*Please note, as referred to in the loan device agreement, a one time fee of R150 will be applicable for insurance on the loan device. Yes No This field is hidden when viewing the formDo you need the loan device before your device is collected for repair / assessment, or can it be sent once we have your device?* Yes, please send it before collection. No, I can wait for the loan device. Make of Device* Apple Samsung Huawei For any of the newer mobile Apple devices from iPhone X to iPhone 15 (including 2021 and 2022 iPhone SE models), please click here to view important information regarding your Apple device’s assessment or repair.Important Notice for Apple Devices*I have read and understood the Important Notice on Apple Devices. Yes Would you like your harddrive to be returned to you?If no, the harddrive will be destroyed in a safe and secure manner to ensure none of your data will be able to be retrieved. If yes, your harddrive will be returned to you. A courier fee may be applicable. Yes No Model NumberWhat is the model number of the item you are claiming for? On phones and tablets, this is written in tiny font on the back cover. On TV’s and consoles, it is usually found on the rear panel. If you are not sure, please try give us the correct model name. Eg: iPhone 6s, Galaxy A3 2017 or Xbox One S. We need to book the correct stock for you, so it is important for us to have the right information to assist you as quickly as possible.Item ColourWhat colour is your item? Knowing this helps us make sure we have the right parts in stock for you. You can skip this step if your item is a TV.What has been damaged?Please select as many relevant options as needed: Screen Back cover / housing Liquid damage Not switching on at all Additional damage / other problems experienced Liquid DamagePlease can you tell us how it happened, or what type of liquid damaged your device?Additional damage / problems experienced*Please give as much detail as possible to help us assess your damaged device as quickly as possible.Any other problems?Have you experienced any other problems with your device, whether before or after the incident that resulted in your claim? No Yes Additional problems:Please give as much detail as possible, including whether this was experienced before or after the incident that resulted in this claim.What area are you in?*Depending on the nature of the damage, and your location, we may be able to send a technician out to you at home or work, or we could collect via courier, or you could drop the device off at one of our branches. We can also do assessments via Zoom – only for devices that turn on and are not liquid damaged. Please ensure that your device is backed-up. Platinum Repairs is not liable for any unexpected data loss during an assessment/repair. Johannesburg Cape Town Pretoria Elsewhere in SA Type of Service required Type of Service required (Courier)* Please send a courier Type of Service required (Virtual)* I’d like to have my device assessed remotely, via Zoom Type of Service required (Drop off JHB)* I’d like to drop it off in Woodmead, JHB Type of Service required (Drop off CPT)* I’d like to drop it off in Paarden Island This field is hidden when viewing the formPlease choose your meeting timeVirtual Assessment This field is hidden when viewing the formJohannesburg/Pretoria*We have a team of debonaire mobile technicians in your area. Depending on the extent of the damage, we could schedule to send one of the gentlemen out to you, to repair or assess your device on-site. Zoom assessments are only for phones and tablets that turn on and are not liquid damaged. We cannot assess TV’s, laptops or consoles remotely. Please ensure that your device is backed-up. Platinum Repairs is not liable for any unexpected data loss during an assessment/repair. I’d like to have my device assessed remotely, via Zoom I’d like to drop it off in Woodmead, JHB Please send a courier This field is hidden when viewing the formCape Town*We have a team of debonaire mobile technicians in your area. Depending on the extent of the damage, we could schedule to send one of the gentlemen out to you, to repair or assess your device on-site. Please only select this option if you are within 50km of Paarden Island, where we are based in CT. Zoom assessments are only for phones and tablets that turn on and are not liquid damaged. We cannot assess TV’s, laptops or consoles remotely. Please ensure that your device is backed-up. Platinum Repairs is not liable for any unexpected data loss during an assessment/repair. I’d like to have my device assessed remotely, via Zoom Please send a courier I’d like to drop it off in Paarden Island This field is hidden when viewing the formWould you like a virtual assessment?*If your device is a phone, tablet or watch, and still turns on, and is not liquid damaged, we can do an assessment via Zoom. Would you like to do that, or rather courier the device to us? We cannot assess TV’s, laptops or consoles remotely – we will have to courier them in. Please ensure that your device is backed-up. Platinum Repairs is not liable for any unexpected data loss during an assessment/repair. I’d like a virtual assessment Please send a courier Time frame for Drop Off:*Please give us an estimated time when you will be able to drop off your device.Schedule virtual meeting: July 2025 Mon Tue Wed Thu Fri Sat Sun 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 July 8, 2025 10:30 11:15 13:30 14:15 15:00 15:45 July 9, 2025 10:30 11:15 13:30 14:15 15:00 15:45 July 10, 2025 10:30 11:15 13:30 14:15 15:00 15:45 July 11, 2025 10:30 11:15 13:30 14:15 15:00 15:45 July 14, 2025 10:30 11:15 13:30 14:15 15:00 15:45 July 15, 2025 10:30 11:15 13:30 14:15 15:00 15:45 July 16, 2025 10:30 11:15 13:30 14:15 15:00 15:45 July 17, 2025 10:30 11:15 13:30 14:15 15:00 15:45 July 18, 2025 10:30 11:15 13:30 14:15 15:00 15:45 I understand that if I select a date that is on a public holiday or a weekend, the courier booking will be processed for the next working day.* Yes Courier Collection Date*On which day would you like the couriers to collect? Collections can only be on weekdays. MM slash DD slash YYYY Should they collect in the morning or afternoon? Afternoon Anytime, before 4pm Collection Address:* Street Address City State / Province / Region Will the device be returned to the same address?*Will the device be returned to the same address as where it was collected from? The delivery address can not be different to the collection address. Yes No Delivery Address* Street Address City State / Province / Region Thank you, we will email you the address shortly after you submit this form. Passcode/PatternWe will need to be able to thoroughly test your phone after repairs, to ensure everything works perfectly. In order to do this, we need to be able to access the phone’s functions. You can either wipe all the data off your phone and reset it to factory settings (with no iCloud or other locks on it) or you can provide us with your passcode or pattern. Your phone will only be accessed for testing – no apps will be opened and your data will remain safe at all times. To send us a pattern code, you can use the diagram below to describe the pattern. I agree to pay the claim excess before the device is returned (if applicable)*If there is a claim excess amount payable, it needs to be paid once your device has been repaired – before your device can be returned to you. Unless alternative arrangements are made with your claim manager at Platinum Repairs, the excess amount is due within seven days of the invoice being sent to you. Yes Additional NotesIs there anything else you would like to add?Terms and Conditions*I have read, and agree to the conditions explained in the linked document, with regards to the Terms and Conditions of Platinum Repairs. For any enquiries, please contact our offices on 010 594 7588 or email us at [email protected]. Yes 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 Would you like to sign up for our mailing list?*Would you like to sign up for our occasional (less than once per month) mailer, to be the first to hear about our new offerings and to receive discount vouchers? Yes No
