Items marked with * are required.
First Name: *
Last Name: *
Company:
Physical Address: *
Address Line2:
City: *
ST/Prov: *
ZIP/Postal Code: *
Daytime Phone: *
Extension:
Evening Phone:
Email Address: *
Surge Protector Model Number: *
If not available, Description of Product:
Date Damage Occurred: *
Store Purchased At: *
Date of Purchase: *
Equipment Claiming Damage On:
Equipment Name, Make/Model, Year Manufactured:
1. *
*
*
2.
3.
4.
5.
Have you had your equipment repaired? Yes
No
If so, where?
Explain damage and what specific parts were repaired or replaced: *
How old is your home, apartment, trailer home?
1-5 yrs
6-15 yrs
16-30 yrs
31-60 yrs
older than 60 yrs
I don't know
If the home is over 30 years old, has it ever been rewired?
Yes
No
If yes, when?
Are the outlets in your home grounded? *
Yes
No
Don't know
Was there inclement weather (lightning)?
Yes
No
Don't know
Was there any construction in your area?
Yes
No
Don't know
Was there power line damage in your area?
Yes
No
Don't know
Did your neighbors experience any problems?
Yes
No
Don't know
Any power outages?
Yes
No
Don't know
If a computer claim, do you have an active modem line?
Yes
No
If a TV/VCR claim, do you have cable or satellite?
Cable
Satellite
Neither
Additional Comments:
Have you filed a claim with your Home Owners (Renters) insurance? *
Yes
No
Have you checked the warranties on your damaged equipment? *
Yes
No
Please describe in detail how all equipment was connected through surge protector, include any telephone/fax and cable/satellite connections: *
Finally, please describe in detail the event in which your equipment was damaged: *
Contact Information