Insurance Claim form Insurance Claim Form Claim # Name * Name First Name First Name Last Name Last Name Phone Number Email Address * Type of device * Cellphone Tablet Smart Watch TV Laptop PC Console Other MacBook or Other? * MacBook Other Make of Device * Apple Samsung Other For any of the newer mobile Apple devices from iPhone X to iPhone 15 (including 2021 and 2022 iPhone SE models), please click here to view important information regarding your Apple device's assessment or repair. Important Notice for Apple Devices * Yes I have read and understood the Important Notice on Apple Devices. Would you like your hard drive to be returned to you? Yes No Model Number What is the model number of your device? This is likely written in small text on the back cover. Example: A1396 for Apple, or SM-/GT-G920F for Samsung. If you are not sure, please try give us the correct model name. Eg: iPhone 6s or Galaxy A3 2017. We need to book the correct stock for you, so it is important for us to have the right information to assist you as quickly as possible. Item Colour If your device is a smartphone or tablet, what colour is it? Knowing this helps us make sure we have the right parts in stock for you. What has been damaged? Screen Back cover / housing Liquid damage Not Switching on at all Additional damage / problems experienced Please select as many relevant options as needed: Liquid Damage Please can you tell us how it happened, or what type of liquid damaged your device? Additional damage / problems experienced * Please give as much detail as possible to help us assess your damaged device as quickly as possible. Any other problems? No Yes Have you experienced any other problems with your device, whether before or after the incident that resulted in your claim? Additional problems: Please give as much detail as possible, including whether this was experienced before or after the incident that resulted in this claim. What area are you in? * Johannesburg Pretoria Cape Town Durban Elsewhere in SA Type of Service required We can do assessments via a Virtual Assessment AI Agent - Please note that we can only do virtual assessments for cellphones, tablets, consoles and TV's that turn on and are not liquid damaged. Type of Service required (Courier) Please send a courier Type of Service required (Mobile) Please send a technician to me Type of Service required (Virtual) I'd like to have my device assessed remotely Type of Service required (Drop off JHB) I'd like to drop it off in Woodmead, JHB Type of Service required (Drop off CPT) I'd like to drop it off in Paarden Island Courier Collection Date * On which day would you like the couriers to collect? Collections can only be on weekdays. Please Note: The courier cut-off time is 10 AM daily. If you submit the form after this, your collection will be automatically scheduled for the next business day. Collection Address * Collection Address Collection Address Collection Address City City State/Province/ Region State/Province/ Region Zip/Postal Zip/Postal Please select a size of the package you are sending. * Cellphone, Tablet, or Smartwatch Size Laptop/MacBook 13-17 inches Laptop/MacBook 18+ inches PC Tower PC Screen 15 - 24 inches PC Screen 25-32 inches TV Size 32-43 inches TV Size 43-65 inches Will the device be returned to the same address? * Yes No Delivery Address * Delivery Address Delivery Address Delivery Address City City State/Province/ Region State/Province/ Region Zip/Postal Zip/Postal Thank you, we will email you the address shortly after you submit this form. Repair Address Where should we send the technician? Once we know where they need to go, we will be in contact to arrange for them to come to you at a time that suits you. Passcode/Pattern We will need to be able to thoroughly test your phone after repairs, to ensure everything works perfectly. In order to do this, we need to be able to access the phone's functions. You can either wipe all the data off your phone and reset it to factory settings (with no iCloud or other locks on it) or you can provide us with your passcode or pattern. Your phone will only be accessed for testing - no apps will be opened and your data will remain safe at all times. To send us a pattern code, you can use the diagram below to describe the pattern. I agree to pay the claim excess before the device is returned (if applicable) * Yes If there is a claim excess amount payable, it needs to be paid once your device has been repaired - before your device can be returned to you. Unless alternative arrangements are made with your claim manager at Platinum Repairs, the excess amount is due within seven days of the invoice being sent to you. Additional Notes Is there anything else you would like to add? Terms and Conditions * Yes I have read, and agree to the conditions explained in the linked document, with regards to the Terms and Conditions of Device Doctor. For any enquiries, please contact our offices on 010 594 7588 or email us at nakedinsure@devicedoctor.co.za. Data Use Consent * Yes I have read, and agree to the conditions explained in the linked document, with regards to the use and protection of my data, in terms of the POPI act. Device Doctor has to comply with the new legislation and require your consent to process your data. Your data will be safe and will not be shared. Submit If you are human, leave this field blank. Δ
