PPS Form

Advisor:

Damage Report, Repair or Salvage?*

Max Auth Amount

Device Replacement Value*

Sum Insured*

Claim #*

First Name*

Last Name*

Phone Number

You can add more than one number if needed.

Email Address*

Risk Address

Please add the address, and collection notes, if needed: Eg: Please hoot at the gate, intercom broken.

Additional Contact Information:

Excess Amount*

Device Make

Device Model

Device Capacity

Colour

Dual-sim?

Damage / Problems Experienced / Notes