|
Work Wireless Claim
This information is to file a preliminary claim report only. The filing of this report does not bind or commit the carrier to accept, respond, or defend any actions resulting from this claim. All coverages are subject to the terms and conditions of the policy. On behalf of the carrier, we reserve all rights, privileges, and defenses available to the carrier under the policy.
Contact Phone
Cell Phone #
City ST Zip
Address
Last Name
First Name
We can not accept P.O. Boxes
Location. ie. Mall, Home, Ballgame
Where
Incident Time
Re-enter your e-mail address
Verify E-mail
Incident Type
Incident Date
E-mail
Make
ESN / IMEI
Model
Supply name and address of location.
How
A detailed description of how the incident occurred.
|