Transcription of LOSS & DAMAGE REPLACEMENT APPLICATION
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Example: air traffic controller
LOSS & DAMAGE REPLACEMENT APPLICATION
Authorized RepresentativeAccount Information Bill to Ship to Serial Number(s) Receiver/Tubing Size and SideAccount AddressTo be completed by client:I hereby apply for a REPLACEMENT hearing instrument(s) for the instrument(s) listed below. The instrument(s) was lost damaged on or about (date) due to the following:I affirm that this loss & DAMAGE REPLACEMENT APPLICATION is not the result of intentional or fraudulent loss or DAMAGE to the original instrument(s) identified by the serial number(s) above. The REPLACEMENT instrument provided by Starkey comes with no loss or DAMAGE coverage. The REPLACEMENT instrument is covered by any warranty or service plan ONLY to the extent that any such coverage that was applicable to the original instrument has not yet expired.
Authorized Representative Account Information Bill to Ship to Serial Number(s) Receiver/Tubing Size and Side
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