Eu Law
YOUR CLAIM FORM
Claim no: 10954683
The excess you must
Policy no: 29869509
£100.00
13-Jan-2014
Date from printed:
1 - YOUR DETAILS
Full name
Mr Ahok Kumar
Address
Previous name
PostCode
Date of Birth
03-11-1987
Previous
Occupation
address (if lived at current
Employment
address for
status
PostCode
2 - PHONE DETAILS - What phone are you claiming for?
Please check your phone details below and provide your handset colour & memory size if applicable.
Make & Model
Handset Colour
APPLE IPHONE 5 16GB
Are the details above still correct?
If "no" please provide details of the phone below
Make & Model
IMEI number
Handset Colour
Yes
Mobile number
Airtime provider
013551008582121
white
07807636761
Orange
Memory size
GB
No
IMEI number
Mobile number
Airtime provider
Memory size
GB
Where did you purchase the mobile phone?
Company name/ Store/ Over the phone/ Web
3 - CLAIM DETAILS - What happened?
What has happened to your mobile phone?
Lost
When did you discover what had happened?
Claim Number:
Stolen
Date
10954683
/
Breakdown
Accidentally
/Faulty
lost
(Please tick one)
damaged
/
Time
:
am/pm
*HCLF10954683F*
Correspondence Address: Customer Service Department, Lifestyle Services Group Ltd, PO Box 98, BLYTH, NE24 9DL
Lifestyle Services Group Limited | Registered office: Osprey House, Ore Close, Lymedale Business Park, Newcastle Under Lyme, Staffordshire, ST5 9QD | Registered in England No. 5114385
England. Registered No: 1026167. Registered Office: 1 Churchill Place, London E14 5HP. Lifestyle Services Group Limited (Financial Services Register No. 315245) is authorised and regulated by the
Financial Conduct Authority in respect of insurance mediation activity only. Barclays Bank PLC (Financial Services Register No. 122702) is authorised by the Prudential Regulation Authority and regulated by
Claim no: 10954683
The excess you must
Policy no: 29869509
£100.00
13-Jan-2014
Date from printed:
1 - YOUR DETAILS
Full name
Mr Ahok Kumar
Address
Previous name
PostCode
Date of Birth
03-11-1987
Previous
Occupation
address (if lived at current
Employment
address for
status
PostCode
2 - PHONE DETAILS - What phone are you claiming for?
Please check your phone details below and provide your handset colour & memory size if applicable.
Make & Model
Handset Colour
APPLE IPHONE 5 16GB
Are the details above still correct?
If "no" please provide details of the phone below
Make & Model
IMEI number
Handset Colour
Yes
Mobile number
Airtime provider
013551008582121
white
07807636761
Orange
Memory size
GB
No
IMEI number
Mobile number
Airtime provider
Memory size
GB
Where did you purchase the mobile phone?
Company name/ Store/ Over the phone/ Web
3 - CLAIM DETAILS - What happened?
What has happened to your mobile phone?
Lost
When did you discover what had happened?
Claim Number:
Stolen
Date
10954683
/
Breakdown
Accidentally
/Faulty
lost
(Please tick one)
damaged
/
Time
:
am/pm
*HCLF10954683F*
Correspondence Address: Customer Service Department, Lifestyle Services Group Ltd, PO Box 98, BLYTH, NE24 9DL
Lifestyle Services Group Limited | Registered office: Osprey House, Ore Close, Lymedale Business Park, Newcastle Under Lyme, Staffordshire, ST5 9QD | Registered in England No. 5114385
England. Registered No: 1026167. Registered Office: 1 Churchill Place, London E14 5HP. Lifestyle Services Group Limited (Financial Services Register No. 315245) is authorised and regulated by the
Financial Conduct Authority in respect of insurance mediation activity only. Barclays Bank PLC (Financial Services Register No. 122702) is authorised by the Prudential Regulation Authority and regulated by