LOST OR DAMAGED INSTRUMENT CLAIM FORM

1 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.

2 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 instruments must be reported to Phonak wwiitthhiinn 1144 ddaayyssof the have the user or responsible party (if user is under 18 years old) describe below the circumstances under which the instru-ment was lost or DAMAGED and the attempts made to recover the INSTRUMENT (attach an additional page if necessary).

3 _____Please have the user or responsible party read and sign the following statement:"I, _____, hereby state that the above information is true and accurate. I understand that should a lost INSTRUMENT be found, the replacement unit I was issued must immediately be returned to Phonak, Inc."Notary Public Stamp_____Notary Public Signature_____DateFOR444 US 10/01 Processed by: _____ Date: _____ Order #:_____PPhhoonnaakk,, 44552200 WWeeaavveerr PPaarrkkwwaayy WWaarrrreennvviillllee,, IILL 6600555555 ((880000)) 777777--77333333 SHIP TO Information.