T-Mobile Documentation Process:
Instructions
Steps to Submit Requested Claim Documentation
Please complete this quick and user friendly form to provide the additional documentation required to
complete your claim. For your claim to be approved and processed you need to complete and submit the
attached claim affidavit, which must be filled out completely and accurately. Carefully follow these steps
to prevent delays in processing your claim.
REQUIRED Steps to Complete Your Claim
1
Complete Fax Cover Sheet (Page 3)
2
Complete and Sign Claim Affidavit (Page 3 and 4)
3
Attach Photocopy of Valid ID (See Examples of Valid IDs on Page 2)
4
Attach Photocopy of Valid Proof of Ownership (See Examples of Valid
Ownership Documents on Page 2)
5
Gather pages 3 & 4 along with copies of ID and Ownership documents.
Fax Documents in the Following Order
1. Page 3 – Fax Cover Sheet / Initial Page of Claim Affidavit
2. Page 4 – Remainder of Claim Affidavit
3. Photocopy of Valid ID (if not already taped to page 4)
4. Photocopy of Valid Ownership Document (handwrite Claim ID on page)
6
Fax T-Mobile Documents to 1-866-502-3171
Important Reminders
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Requirement - Fill in all fields on the claim affidavit entirely. The claim affidavit must also be signed by the
insured or an authorized user on this account.
If you fax the same document multiple times it can lead to delays in processing your claim.
Please DO NOT fax the instruction pages when returning your completed documents. Only fax pages 3 and 4 of
this document along with photocopy of your ID and ownership document.
When faxing, determine if the fax machine wants pages to be fed face down or face up. If faxed incorrectly the
pages being transmitted to Asurion may be upside down and result in blank pages. If this happens delays in
processing your claim will occur.
If you have additional questions about this process, please call Asurion at 1-866-268-7221.
Once reviewed an Asurion representative will contact you to inform you of the next steps.
Fax T-Mobile
Documents to:
1-866-502-3171
(Toll Free)
OR
Mail Documents to:
Claims Documentation Processing
648 Grassmere Park Dr. Suite 200
Nashville, TN 37211
Note: If mailed, the claims process will be dependant on
timeline of mail delivery and will take longer to complete
your claim than faxing.
IMPORTANT LEGAL NOTICE: A person who knowingly presents a false or fraudulent insurance claim with the intent to injure,
defraud, or deceive any insurer is guilty of a crime and may be subject to fines and confinement in state prison. When fraud is
discovered, Asurion takes appropriate steps to stop such fraud and explore all of its available legal remedies.
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T-Mobile Documentation Process:
Instructions
Examples of Valid Personal Identification
The following types of personal identification will be considered valid forms for this submission process:
1. Government issued ID / drivers license
3. Passport issued by Government
5. US Military ID Card
2. Visa (Green Card / Alien Card)
4. College / High school ID card (Recognized US Institution)
Important Reminders:
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The name on the identification must match that of the insured who is filing the insurance claim or the name of an
authorized user on the account. If the name doesn’t match that of the account owner or an authorized user then
additional documentation may be required.
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All forms of identification must be legible, unaltered, and legitimate. If the identification appears altered, forged, or not
legitimate then efforts to proceed with the claim will require a licensed Asurion Insurance Adjuster to review the claim
in its entirety.
EXAMPLES - Following are examples of valid forms of photocopied personal identifications:
1. Drivers License
2. Visa Card
3. Passport
4. School ID
5. US Military Card
Examples of Valid Ownership Documents
The following types of ownership documents will be considered valid forms for this submission process:
1. Service Agreement
4. Wireless Bill Within Last 60 Days Displaying 1 Time Equip. / Upgrade Charge
2. Store Receipt
5. UPC Bar Code From Original Box in which Phone was Purchased
3. Copy of the Back of the Phone Being Claimed with Battery Removed (Only on Damaged Claims)
Important Reminders / Requirements:
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All examples must clearly show make and model of the phone plus display the 15 digit IMEI number
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All examples except #3 & #5 (Back of Phone / UPC Code) must show customer name and wireless phone number
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Service Agreement and Store Receipt must show store name, store address and phone number, and dealer code
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Store Receipt must also show the invoice number
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Wireless bill must be less than 60 days old and show 1 time equipment or upgrade charge
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Due to ownership document being on a separate page please handwrite Claim ID # on it before faxing
EXAMPLES - Following are examples of valid forms of photocopied ownership documents:
1. Service Agrmnt.
2. Store Receipt
3. Back of Phone
4. Recent Wireless Bill
5. UPC Code From Box
You may call Asurion at 1-866-268-7221 if you have questions regarding these instructions or affidavit form.
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T-Mobile Documentation Process:
Fax Cover Sheet and Affidavit
Fax Cover Sheet Information
To: Asurion Claims Documentation Processing
T-Mobile Fax Number: 1-866-502-3171
Re: T-Mobile Documentation Process
Total Number of Pages Being Faxed:
Claim Affidavit
FILL IN ALL FIELDS USING BLACK OR BLUE INK AS THEY ARE REQUIRED FIELDS.
FAILURE TO DO SO WILL DELAY YOUR CLAIM.
IMPORTANT LEGAL NOTICE: A person who knowingly presents a false or fraudulent insurance claim with the intent to injure,
defraud, or deceive any insurer is guilty of a crime and may be subject to fines and confinement in state prison. When fraud is
discovered, Asurion takes appropriate steps to stop such fraud and explore all of its available legal remedies.
1. Personal Information of Account Owner:
Claim ID#:
(Number previously provided to you by Asurion representative)
Mobile # of phone that was lost, damaged, malfunctioning, etc. (
)
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Insured's First Name:
Insured's Last Name:
Daytime Phone #: (
)
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Extension:
Evening Phone #: (
)
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Extension:
Last 4 Digits of Social Security Number on Account:
Handwrite your E-Mail address: _________________________________________________________
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To ensure customer privacy Asurion will not share your contact information with external parties. Asurion will only use your e-mail address to
contact you if we have questions and / or if your documentation is approved and your claim is ready to proceed.
Home Address:
Handwrite your address if it will not fit in above boxes: _________________________________________
____________________________________________________________________________________
City:
Zip Code:
State or Province:
Country (Only if outside of continental US):
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T-Mobile Fax # 1-866-502-3171
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T-Mobile Documentation Process:
Affidavit Continued
2. Equipment and Claim Details
Phone Manufacturer (Ex. Motorola, Nokia, Samsung, etc.):
Model Name and Number (Ex. RAZR, 6086, t409, etc.):
IMEI (IMEI = 15 digits):
Phone Manufacturer, Model Name and Number, and IMEI (International Mobile Equipment
Identification Number) are located on the back of your phone behind the battery (see
example to the right). It’s also on the original box the phone came in, on your monthly
wireless bill, or you can contact T-Mobile Customer Service to obtain the information.
Check one (1) of the following Loss Types – Your phone was…
Lost
Stolen
Damaged (Dropped, Water Damage, Broken, etc.)
Date phone was lost, stolen, damaged, or malfunctioned (MM/DD/YYYY):
Malfunctioning:
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Last known location when phone was lost, stolen, damaged, or began malfunctioning: _______________
Detailed description on what happened to your phone: ________________________________________
___________________________________________________________________________________
Note: If your phone was damaged or malfunctioning, you are required to return it to Asurion upon receipt of your replacement phone.
3. Attach Photocopy of Your Valid Government Issued Photo ID (See Examples on Page 2)
Tape photocopy of your ID here
OR
Send a copy of it on a separate page and fax at
the same time with your other required
documents. Please enlarge the copy and
ensure it’s readable. Please handwrite your
Claim ID # on the document.
Check type of photo ID you are attaching:
Govt. ID / Drivers License
Military
Passport/Visa
Other
Please clearly print the name and number on
the ID being provided:
Name:_______________________
Number:_____________________
4. Attach Photocopy of an Ownership Document (See Examples on Page 2)
Check type of document you are attaching:
Service Agreement*
Store Receipt*
Copy of Wireless Bill**
Copy of UPC bar code and phone model from top or side of original box
Back of Phone - Copy
* MUST SHOW MAKE / MODEL, IMEI OF THE CLAIMED DEVICE, AND RETAIL STORE INFORMATION
** WIRELESS BILL MUST BE LESS THAN 60 DAYS OLD AND DISPLAY 1 TIME EQUIPMENT OR UPGRADE CHARGE
Fax a copy of the ownership document as a separate page. It should be faxed at the same time with all other requested documents in this form.
5. Claim Agreement
Claim ID#:
I hereby make an insurance claim against the insurance company as shown on this insurance claim affidavit. I
acknowledge that if any property which is the subject of this claim and which is replaced or paid for by the insurer is
recovered at any time, it is the property of the insurance company and must be returned to the insurance company.
I understand that if I fail to return such property, I am subject to, and authorize a non-return fee of up to $300 to be
charged under the insurance policy using the method of payment used to originally file this claim.
I swear/affirm that the wireless phone I am claiming is owned by me and is on file with my wireless carrier and that the
information provided above is true and accurate. I understand that any false or misleading statement made herein is
fraud and I may be found guilty of a crime. Asurion has, and will take all legal action possible in the event of a
fraudulent claim
Insured Signature: ________________________
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Sign Date:
T-Mobile Fax # 1-866-502-3171
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