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If this product is a Surge Protector or an Uninterruptiple Power Supply (UPS) please answer the following question: Is there any damage to connected equipment?* YES NO  
Model Number:*
Name (First, Initial, Last)*
Street Address 1:*
Street Address 2:
Zip Code:*
Phone Number:* ( ) - -
Fax Number:* ( ) - -
E-mail Address:*
Belkin Order Number:
(Issued through Belkin online
purchases only; e.g. IW123456)
Date of Purchase:* / /
Name of retail or online
store where purchased:*

Tell us why you would like to make a claim:*

Average response time is 1-3 working days.

Please Note: All product warranties are limited. Products purchased from third parties,
most specifically auction site sales, are not warranted for replacement.

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