MTN Device or Accessory Insurance Claim Form

NOTE: The claims process starts with FULL COMPLETION of this form, all fields are MANDATORY, and the claim will be delayed if not completed accurately. All lost or stolen Devices
or Accessories MUST be blacklisted prior to the claim being attended to and within 48 hours from the date of loss.
Please contact MTN who will assist you with blacklisting your phone.
This form and all supporting documents required MUST be submitted within 30 days from date of loss. Please include a copy of your ID document.

Claims Declaration - Complete and Return to Worldwide Advisory Services (Pty) Ltd

Customer Information
Cellphone Number 0 - -

Name of Policy Holder

ID Number

Contact Person
0 - -
Contact No
0 - -
Secondary Contact No

Email for correspondence

Preferred communication Call SMS Email

Do you have an e-Sim – please

provide the e-Sim number
NB: Delivery address for courier of
new or replacement Device or
Accessory

Please ensure that all below fields are completed in full in relation to the type of claim.
Please be advised that any missing information or lack of supporting documentation will lead to a delay in the processing of the claim.

Theft and Loss

Theft Loss
Device or Accessory Details: Device or Accessory Make & Model: Colour:
Place of Loss: Date & Time of Loss:
IMEI Number 1:

IMEI Number 2:

Detailed description of events leading to claim Please ensure that full details are provided to avoid claim delay:
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................

Blacklisting and Police Information

Please ensure that you blacklist the device with your network provider (MTN) by calling their customer care line on 083135. A customer care representative will provide you with
an ITC reference number (via SMS/email) which will confirm that your device has been blacklisted.

S.A. Police Station Name:

S.A.P Case No: Date Reported:

ITC REFERENCE: (Blacklisting ref) Date of Blacklisting:

Theft from a vehicle (A copy of the invoice for repairs to your vehicle must accompany this claim form)
How was entry gained? Were all doors locked?
Where in the vehicle was the Device or Accessory at the time of theft?

Who repaired the damage to the vehicle?

Tel: 083 123 6084 | E-mail: [email protected] | MTN Device Insurance is administered by Worldwide Advisory Services and underwritten by Santam Limited | Admyntec
Services is a Juristic Representative of Worldwide Advisory Services, a registered financial service provider FSP No. 12964 | Santam is an authorised financial services provider (FSP
3416), a licensed non-life insurer and controlling company for its group companies
 Damage
Accidental Liquid
Device or Accessory Make & Model:
Place of Damage: Date & Time of Damage:
IMEI Number 1:

IMEI Number 2:

Detailed description of events leading to claim: Please ensure that full details are provided to avoid claim delay:
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
Describe the problems occurring with the Device or Accessory since the damage occurred:
....................................................................................................................................................................................................................................
What is the collection address of the damaged Device or Accessory?
....................................................................................................................................................................................................................................

Please supply a copy of your ID document and if a theft occurred from a vehicle, home or office proof of forcible and violent entry must be provided.
• Please ensure that only the battery and back cover are submitted with the handset and that the SIM card and any MEMORY card is removed from the Device or Accessory. Kindly note
that the Device or Accessory may be wiped for testing, quality control and security purposes so please backup all data prior to collection.
• Excess: Excesses differ depending on the insurance product. The claims department will advise you on the excess payable or revert to the policy schedule.
• Should you fail to pay the required excess on the approved claim, for your Device or Accessory, within 90 (ninety) days from the date of loss, the claim will be suspended and prescribed
after 12 months.
• I understand that I am fully bound by the representations made in this statement and that any misrepresentation of the facts gives the Insurer the right to repudiate my claim and to
cancel my policy with immediate effect. Furthermore, I declare that I have no other insurance on the Device or Accessory claimed for above.

Insured Signature: .........................................................................................................................................................................

Name: (Block Letters) .............................................................................................................. Date: .................................................

Tel: 083 123 6084 | E-mail: [email protected] | MTN Device Insurance is administered by Worldwide Advisory Services and underwritten by Santam Limited | Admyntec
Services is a Juristic Representative of Worldwide Advisory Services, a registered financial service provider FSP No. 12964 | Santam is an authorised financial services provider (FSP
3416), a licensed non-life insurer and controlling company for its group companies