Claim Declaration Form

Claim Type : DAMAGE ISSUE Date: 17/9/2018

Name of the Customer: ___________________________________

MUDIT DUA

Contact / Mobile Number: _____________________________________

9530778828

Service Order / Reference #:____________________________________

8011810802

System Serial Number: ________________________________________

PF0WEGFS

Model / Type: _______________________________________

LEGION Y520

Date & Time of the loss / damage: ________________________________

11/08/2018
Place of Incidence: _____________________________________________
HOSTEL
Brief description of the loss / damage:

______________________________________________________________________________
There was a crack on the back cover of the screen, which was unknown to me
______________________________________________________________________________
for a while , after it the crack started increasing gradually due to regular use of laptop.
______________________________________________________________________________
The crack at the hinge and the bazel has also opened due to which the flap has become
______________________________________________________________________________
very loose and delicate.
______________________________________________________________________________
The right click of the touchpad is not responding properly. I have to click very hard
______________________________________________________________________________
to make it work.
Declaration:

I / We agree to provide additional information to the company, if required. I /We, the above
mentioned do hereby, to the best of my / our knowledge and belief warrant the truth of the
foregoing statement in every respect, and if l / We have made, or in any further declaration the
company may require in respect of the said loss / damage. If any of the above is false or
fraudulent / any suppression or concealment of details if / when subsequently discovered, the
coverage / protection shall be void for the above mentioned unit and the company reserves the
right to recover the costs in full / part from me / us.

I have / will receive my device repaired / replaced by authorized service center.

Mudit
Signature of the Customer.