Control# F-017-48-AEN Rev 19 EDT: 11/1/07 RDT: 10/26/12 Asurion Documentation Process Instructions-DO NOT FAX THIS PAGE

REQUIRED Steps to Complete Your Claim Must be completed by primary account holder 1 Fill out and sign the Claim Affidavit Document 2 Attach the summary page of your most recent Wireless bill (within the last 60 days) 3 Attach a Photocopy of Valid ID (See Examples of Valid IDs below) 4 Attach a valid Proof of Purchase if appropriate (See examples of valid proofs of purchase below) 5 Please upload your documents to www.phoneclaim.com/att-uploader or Fax your documents to 1-888-429-7719. Once your claim is completed please visit www.phoneclaim.com/att to check the status of your claim. Examples of Valid Personal Identification . Student IDs, work IDs, birth certificates and Social Security cards are not acceptable as valid identification. . The name on the ID must match the name of the primary account holder. If the name does not match, then additional documentation may be required. When faxing, lightening and increasing the size of your ID assists with your document review. When using the Web Uploader please be sure to verify that the image is not distorted or blurry. . All forms of identification must be legible, unaltered, and legitimate. The ID also cannot be expired. If the ID appears altered, forged, or not legitimate, we will not be able to proceed with your claim. Drivers License Federally or State Issued ID Card US or Foreign Passport Matricula Consular ID US Military ID Card (Active and Retired) Please attach the summary page of your most recent Wireless bill (within the last 60 days) Examples of Proof of Purchase (include one photocopy of any of the following) 1. Store Receipt must be an electronic register receipt or purchase receipt with ESN/MEID/IMEI and make & model of device 2. Back of Phone/Device battery must be removed and ESN/MEID/IMEI must be clearly visible (**DOES NOT APPLY TO IPHONE MODELS**) 3. UPC Code From Box - must show ESN/MEID/IMEI of device being claimed 4. Packing Slip must show the contents of shipment for device and ESN/MEID/IMEI being claimed 5. Service Agreement - must show the make, model and ESN/MEID/IMEI of device being claimed EXAMPLES - Following are examples of valid forms of photocopied ownership documents: Store Receipt Back of Phone UPC Code From Box Service Agreement All documents must be legible. Once we receive the items listed above, we will complete our review of your claim. You must return all documentation to the address listed on the affidavit within 60 days of the date you requested your replacement as provided in the Coverage Certificate or your claim may be denied. If you have any questions, please contact us at 1-888-562-8662. *In California, Asurion Protection Services Insurance Agency, LLC (CA License Number: OD63136); in Puerto Rico, Asurion Protection Service of Puerto Rico, Inc. Puerto Rico Resident Agent Jorge J. Amadeo, Eastern America Insurance Agency, Inc. Control# F-017-48-AEN Rev 19 EDT: 11/1/07 RDT: 10/26/12 Sworn Affidavit and Proof of Loss Statement ALL FIELDS ARE REQUIRED AND MUST BE FILLED IN (PLEASE PRINT) USING BLUE OR BLACK INK. Upload Documents at: www.phoneclaim.com/attuploader Fax Documents to: 1-888-429-7719 Mail Documents to: Asurion Attn: Review Team P.O. Box 413886 Kansas City, MO64141-3886 Note: If mailed, the claims process will be dependent on the timeline of mail delivery and will

take longer to complete your claim than faxing. IMPORTANT LEGAL NOTICE: Any person who knowingly and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete, or misleading information is guilty of insurance fraud, which is a crime. All claim files and documentation, including this affidavit, are subject to inspection by the various State Departments of Insurance. Wireless device number ( 407) 721-0475 I. Personal Information of Account Holder: First and Last Name: Angelo Rodriguez Daytime Phone Number: 407-721-0475 Evening Phone Number: E-mail Address: [email protected] Mailing Address: 582 Bohannon Blvd City: Orlando State: Florida Zip Code: 32824 2. Equipment and Claim Details(See Instructions on Page 1) Device Manufacturer (Ex. Apple, Motorola, Blackberry, Samsung, etc.): Model (Ex. iPhone 4S, Atrix, Curve, Captivate, etc.) : Check one (1) of the following Your device was Lost Stolen Damaged Malfunctioning Date of occurrence : 2-14-2013 Place of occurrence: Home Detailed description on what happened to your device: I was holding the phone it rang and fell out of my hand and the screen cracked Note: If your device was damaged or malfunctioning, you are required to return it to Asurion upon receipt of your replacement phone. 3. Attach the summary page of your most recent Wireless bill (within the last 60 days) 4. Attach Photocopy of Your Valid Government Issued Photo ID (Please be sure to lighten & enlarge your ID, and clearly write your claim number and wireless number.) 5. Attach one Proof of Purchase document if required (See examples on instruction page) 6. Claim Agreement I hereby swear or affirm that I have completed the foregoing, and the facts alleged are true, to the best of my knowledge and belief. Signature: Angelo Rodriguez Date:02/24/2013