Claim Registration Form

CLAIM REGISTRATION FORM-ORA Policy

FIRST NAME

(Name as per the policy)

LAST NAME

(Name as per the policy)

EMAIL ID

MOBILE NUMBER

ALTERNATE CONTACT NUMBER

(Optional)

POLICY NUMBER

IMEI NUMBER / SERIAL NUMBER

(Kindly input any one IMEI Number)

DEVICE

iPhone Android SmartPhone Laptop iPad Tablet Television SmartWatch Home-Appliance Other

NATURE OF CLAIM

Screen/Display Damage Back Glass/Panel Damage Liquid Damage MotherBoard Problem
Malfunctions Device not working Warranty Related Issue Not sure about issue
Theft/Stolen/Robbery Other Issue

DATE OF INCIDENT

CLAIM DESCRIPTION

ADDRESS

CITY

(max 30 characters a-z and A-Z)

PIN CODE

(6 digit number)

STATE

(max 30 characters a-z and A-Z)

COUNTRY

ONLY FOR CORPORATES

Nature Of Claim	Devices	No. Of SmartPhone(s)	No. Of Laptop(s)	No. Of iPad(s)
1	Damage
2	Theft
3	Malfunctions
4	Others
		(10,000 SmartPhones max)	(10,000 Laptops max)	(1000 iPads max)