Transcription of LOST OR DAMAGED INSTRUMENT CLAIM FORM
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LOST OR DAMAGED INSTRUMENT CLAIM FORM
LLOOSSTT OORR DDAAMMAAGGEEDD IINNSSTTRRUUMMEENNTTCCLLAAIIMM FFOORRMMThe following section is to be filled in by the dispenser:Account Number: _____Account Name: _____Address: _____User's Name: _____Model name: _____Serial Number: _____Original Invoice #:_____Original Invoice Date:_____Dispensing Date: _____Warranty Expiration: _____(Signature/Date)_____(Signature,Dis pensing Agent/Date) PPLLEEAASSEENNOOTTEE:: Phonak, Inc. will replace a hearing INSTRUMENT that has been certified as lost or DAMAGED beyond repair only once duringthe lost and damage period after dispensing. IInnssttrruummeennttss rreeppllaacceedd uunnddeerr tthhee LLoossss aanndd DDaammaaggee pprroovviissiioonn mmaayy nnoott bbee rreettuurrnneedd ffoorr CCllaaiimmss wwiillll bbee pprroocceesssseedd oonnllyy wwhheenn tthhiiss ffoorrmm iiss ccoommpplleetteedd aanndd Phonak reserves theright to request additional information regarding this CLAIM if deemed necessary for settlement.
LOST OR DAMAGED INSTRUMENT CLAIM FORM The following section is to be filled in by the dispenser: Account Number: _____ Account Name: _____
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