CEPP Claim Form - Smart Power Systems - Emerge Power Solutions

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CONNECTED EQUIPMENT PROTECTION POLICY CLAIM FORM

Requested RMA # *

Date *

Customer Name or Distributor *

Contact Name *

End User's Address *

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Phone *

Fax

About Your Damaged Connected Equipment

Damaged Connected Equipment *

" id="item-vfb-349">Unit Model Number * " id="item-vfb-350">Serial Number * " id="item-vfb-351">Brand Name * " id="item-vfb-352">How old is the damaged equipment? * " id="item-vfb-353">Has any other insurance claims been filed? * " id="item-vfb-354">Damage Claim $ - (receipts/invoices for damages required) * " id="item-vfb-355">Is the damaged equipment covered by any factory warranty? * " id="item-vfb-356">Please describe claim condition: * " id="item-vfb-357">What date did the damage to the equipment occur? * " id="item-vfb-358">Were there any storms or lightning strikes in the area? * " id="item-vfb-360">Did the connected equipment stop working immediately? * " id="item-vfb-361">Were there any telephone lines being used on the systems? * " id="item-vfb-362">Were there any Network connections being used on the Emerge Power Solutions unit in conjuction with the equipment, such as RJ45, or cable? * ">

About Your Emerge Power Solutions' Equipment

How exactly is our power filter connected to the connected equipment? *

" id="item-vfb-374">Emerge Power Model Number * " id="item-vfb-375">Emerge Power Serial Number * " id="item-vfb-376">Is the Emerge Power unit damaged? Explain *

" id="item-vfb-377">Comments *

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Verification

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order to process any claim we must have the following items:
• Emerge Power Solutions product
• Damaged connected equipment or part.
• Warranty information
• Repair invoice(s).

After further testing and diagnostics the claim information will be processed accordingly.

Note: No claim will be processed without the request of an RMA # from Emerge Power Solutions. No claim will be processed if the requirements above are not met.