Connected Equipment Warranty Claim Form for Surge Protector and UPS

(* required fields)

Customer Information
 Claim Date: 7/10/2014 1:43:14 AM *Part No.:
  Other Part No.:

 *Name:                * First     * Last
 *Physical Address :    
  Address 2/P.O. Box: *Daytime Phone: - -
 *City: *Evening Phone: - -
 *State/Province: *E-Mail Address:
 *Zip/Postal Code:    

 *Purchase Location: *Purchase Date: / /
 *Cause of failure: (please limit to 500 characters)    
 *Date of Incident: / /
Insurance Information
* Do you have Homeowner's, Renter's, or any other form of applicable insurance policies? Y N   (if answered Yes, must answer next question)
  If yes, who is your insurance company?

 *Are you filing a claim with your insurance company? Y N  
  If yes, what is your deductible ($ amount)? $  Claim No. :   
  Name of insurance representative:       Phone No.: ( ) -
Connected Devices
Please fill out the following list of the devices damaged while properly connected to the Belkin surge protector. This claim is valid only for the items and surge protector listed. Any deviation will result in the cancellation or delay in processing the claim.

PLEASE NOTE: It is important that all the fields for connected devices are not left blank. If you accidentally hit "Add Another Device" without the intention of adding an additional device to the list, please enter 'N/A' for any blank fields and select 'N' when asked if the device has been damaged.

*Connected Devices
(list all)
*Model #
*Serial #

IMPORTANT: Your claim form is not valid until it is signed and mailed to Belkin along with your surge protector within 30 days from the request date. To obtain the printable version of your claim form and important shipping instructions, please proceed by clicking "Next" below.