Fillable OR Claim Facilitation Form

Fill Online, Printable, Fillable, Blank OR Claim Facilitation Form Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

OR Claim Facilitation Form

On average this form takes 6 minutes to complete

The OR Claim Facilitation Form form is 1 page long and contains:

  • 1 signature
  • 2 check-boxes
  • 19 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Claim Facilitation Form
ALL FIELDS MUST BE COMPLETED. PLEASE USE FILL & SIGN TO COMPLETE ELECTRONICALLY OR PRINT TO
COMPLETE FORM MANUALLY USING BLUE OR BLACK INK.
Upload your Documents to:
https://protection.asurion.com/protection-plan/
en-us/doc-uploads
OR
Email Documents to:
Attention: ASURION Claims Review Team
MyClaimStatus@asurion.com
Note: Uploading documents is always the preferred method of transmission.
Emails may take additional time to locate and review.
ENROLLED LAST NAME:
ALTERNATE PHONE:
STATE/ PROVINCE:
POSTAL CODE:
IMPORTANT LEGAL NOTICE: A person who knowingly presents a false or fraudulent service contract claim with the intent to injure, defraud, or
deceive any insurer is guilty of a c
rime and may be subject to fines and confinement in prison. When fraud is discovered, ASURION takes
appropriate steps to stop such fraud and explores all of its available legal remedies.
Personal Information of Enrolled Subscriber:
Drop, Spill, or Cracked Screen
Malfunction
I hereby initiate a claim against the service contract company as shown on this claim validation form. I swear/affirm the product I am filing a claim for is owned by me,
and that the information provided is true and accurate. I understand that any false or misleading statements made herein are fraud and I may be found guilty of
a crime. ASURION has a right and will take all legal actions possible in the event of a fraudulent claim.
Signature:
Date:
ENROLLED ACCT #:
ENROLLED FIRST NAME:
ENROLLED PHONE:
ENROLLED EMAIL:
SERVICE ADDRESS:
CITY:
Product Details:
PRODUCT DESCRIPTION:
MANUFACTURER:
MODEL NUMBER:
SERIAL NUMBER:
Claim Details:
SERVICE REQUEST #:
MY FAILURE IS A:
DESCRIBE FAILURE:
DESCRIBE WHAT
HAPPENED:
DATE OF FAILURE:
Claim Agreement:
Asurion_Public
©2021 Asurion, LLC. All rights reserved.
COV54082
Save
Upload
click to sign
signature
click to edit
How to Submit Required Documentation
1. Fill out the Claim Facilitation Form completely. Please be sure to sign the document prior to submitting.
2. Upload completed documents to https://protection.asurion.com/protection-plan/en-us/doc-upload
Frequently Asked Questions:
• Where do I find my model number and serial number?
o Model and serial numbers are generally located on the back of the product. In some cases you may need to
check the "About" section of your settings to obtain your model and serial number.
• How long will it take for my claim to be reviewed once I send in my claim form?
o You should receive an email response (If provided) from MyClaimStatus@asurion.com within 1 business day of
uploading your documentation. Please noted that emailed, faxed, and mailed document review time frames
are longer.
• What if I am unable to download and print the form?
o Contact our Claim Review Team to request a mailed copy.
• How long do I have to submit my paperwork?
o Your claim will remain in a review status for 60 days from initiation. If we have not received your paperwork
within that time, we will cancel your claim for inactivity. This does not prevent you from filing another claim in
the future, so long as your plan is active.
REMINDERS:
•
FILL OUT ALL FIELDS, SIGN, AND DATE THE CLAIM FORM PRIOR TO UPLOADING IT. INCOMPLETE FORMS WILL NOT BE APPROVED.
•
SIGN YOUR CLAIM FORM USING A DIGITAL OR INK SIGNATURE. FORMS SUBMITTED WITH TYPED OR PRINTED SIGNATURES WILL NOT
BE APPROVED.
•
YOU CAN CONTACT ASURION CUSTOMER SERVICE IF YOU HAVE QUESTIONS REGARDING THE INSTRUCTIONS FOR COMPLETING OR
SUBMITTING THE CLAIM FORM. THIS NUMBER CAN BE LOCATED ON YOUR PROTECTION PLAN INFORMATION.
Asurion Claim Facilitation Form
Instructions
I
Instructions
Do not upload or email this page
Asurion_Public
©2021 Asurion, LLC. All rights reserved.
COV54082
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

OR Claim Facilitation Form

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 12 March 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document