BDP US1 Rev. 3/18 Page 2
WIRELESS EQUIPMENT REPLACEMENT AFFIDAVIT
IMPORTANT LEGAL NOTICE: A person who knowingly makes or presents a false or fraudulent Affidavit with the intent to
injure, defraud, or deceive may be guilty of a crime and may be subject to fines and confinement in prison. When fraud is
discovered, Brightstar Device Protection will take appropriate steps to stop such fraud and will pursue all available legal
remedies.
Section I: Subscriber Information
Mobile Number Enrolled Subscriber’s Printed
Name Wireless Carrier
Billing Address
City State
Zip Code
Email address Contact Number(s)
You must submit a valid copy of one of the government-issued IDs listed below. Please select the type submitted.
□
State or Federally Issued ID
□
Immigrant Visa
Section II: Replacement Request Details
If your device has been lost or stolen, before submitting this Affidavit you must report your device as lost or stolen to your
wireless carrier and the device must be suspended or deactivated on your carrier’s network. By submitting this Affidavit, you
acknowledge and certify that you have reported your lost or stolen device to your wireless carrier and have requested that
the device be suspended or deactivated on your wireless carrier’s network.
Loss/Incident/Failure Date ___________________________________
Device Make/Model
My device i
s (select one):
Please describe the loss, incident, or failure:
Section III: Sworn Statement
I hereby make a Replacement Request against the insurance company/service contract provider as shown on this
Affidavit. I acknowledge that if any property which is the subject of this Replacement Request and which is replaced or
paid for by the insurance company/service contract provider is recovered at any time, it is the property of the
insurance company/service contract provider and must be returned to the insurance company/service contract
provider. I understand that if I fail to return such property, I am subject to, and authorize, a non-return fee using the
method of payment used to originally file this Replacement Request. A certified electronic signature shall have the
same effect as an original signature.
I swear/affirm that the wireless device I am claiming is owned by me and that the information provided above is true
and accurate. I understand that any false or misleading statement made herein is fraud and I may be found guilty of a
crime. Brightstar Device Protection, LLC will take all legal actions possible in the event of a fraudulent Replacement
Request.
Enrolled Subscriber’s Signature Date
□
Driver’s License
□
Resident Alien Permit
□
Passport
□
Stolen
□
Lost
□
Malfunctioning
□
Damaged
click to sign
signature
click to edit
![]()
