Power Surge Electronics Damage Claim
Policyholder Information
Full Name
Address
Contact Number
Email Address
Policy Number
Incident Details
Date of Incident
Time of Incident
Incident Location
Description of Incident
Damaged Electronics
Item
Brand/Model
Serial Number
Purchase Date
Purchase Price
Estimated Repair/Replacement Cost
Additional Information
Have you filed a police report?
Have you filed a claim with your electricity provider?
Other Relevant Details
Signature
Date