New Leaf Service Contracts

Claims Facilitation Form

Customer First Name:

Customer Last Name:

Customer Phone (Digits Only):

Sales Order Number:

Customer Email:

Communication Preference:

Phone

Address:

Is this a business?

Yes No

City:

State:

Zip:

Product Description:

Model:

Manufacturer:

Purchase Date:

Serial:

Retailer:

Unit Failure Description :

Accidental Damage Claim:

Furniture Claim:

Date Failure was Identified:

Attach Invoice and/or Images:

Person Submitting Request:

Person Submitting Request Phone:

Person Submitting Request Email:

Has anyone in the home been diagnosed or tested due to symptoms for COVID-19 in the last 14 days?

Has anyone in the home has any combination of symptoms consistent with COVID-19 in the last 7 days?

Has anyone in the home come in close contact (within 6 feet) with someone who has been diagnosed with or waiting test results for COVID-19 due to symptoms within 14 days?

Date of Request:

2024-Oct-03