Unit 1 Radon Park

379 Bergvlei Road

Wadeville Ext4
P.O. Box 752159
Gardenview 2047 Claim No.
Tel: +27 11 865 4628
Fax: +27 11 865 5655
www.africasurge.com
sales@africasurge.co.za
WARRANTY CLAIM FORM
(Please fill in and return as soon as possible to Africa Surge)

1. CLIENTS DETAILS
Name:
Address (where incident happened):

Tel:
Fax:
Cell:
e-mail:

2. Electrical Certificate of Compliance – Please attach a copy of the COC with this claim form.
3. Obtain three quotes with damage reports for the repair of the equipment.

4. Reason for Claim:

5. EQUIPMENT DETAILS
Equipment Under Claim: S/N:

Is the Equipment still under a manufacturers warranty / guarantee? YES / NO

Do you have housing hold insurance or any other insurance that covers the equipment under claim? YES / NO

Insured By: Broker Name:

Address:

Tel:
Fax:
Contact Person:

I the undersigned state the above information to be true and correct, and if any of the information given above is found to be
incorrect, am liable for all expenses incurred by Africa Surge Protection (Pty) Ltd.

______________________________ ___________
(Customers) Date:

______________________________ ___________
(Witness) Date:
J Roper (Managing Director)
Africa Surge Protection (Pty) Ltd
2003/005684/07