Street Address

City, State, Zip

855-720-2361

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Name

First Name

Last Name

Email Address

Phone

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Approximately when did you purchase the product or service you are issuing a claim for?

Do you have a sales receipt for your product or service?

Yes

Is your claim currently covered by a contract, service agreement or warranty?

Yes

What is the estimated value of the item or service you are claiming?

Have you contacted anyone at the company regarding your claim?

Yes

If yes, do you have documentation (email or phone log)?

Yes

Please briefly describe your claim

(Please note that we do not currently offer resolutions for utility, phone or cable bills.)

INDIVIDUAL RETAILS CLAIM qUESTIONNAIRE

Please fill out this form and a representative from mycustomeradvocate will get back to you promptly.

If you need assistance, please call us toll free at 855-720-2361.