Claims Nomination Forms

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Personal Details

Surname*

Title

First Name*

Your Email*

Tel*

Postal Code*

Address*

Switched Product Details

**IMPORTANT NOTICE**

The below registration is for the appliances connected to our Switched products and not the product itself. E.g. TV connected to a Switched High Surge Multiplug (The claim would be for the TV) Name of Appliance: Hisense TV | Serial Number of TV: 745825HGT | Approx Rand Value of TV: 4600

Name of Appliance:*

Serial number of Appliance:*

(Optional)

Approximate Rand Value:*

(Optional)

Name of Appliance:

Serial number of Appliance:

(Optional)

Approximate Rand Value:

(Optional)

Name of Appliance:*

Serial number of Appliance:*

(Optional)

Approximate Rand Value:*

(Optional)

Name of Appliance:

Serial number of Appliance:

(Optional)

Approximate Rand Value:

(Optional)

Name of Appliance:*

Serial number of Appliance:*

(Optional)

Approximate Rand Value:*

(Optional)

Name of Appliance:*

Serial number of Appliance:*

(Optional)

Approximate Rand Value:*

(Optional)

Name of Appliance:

Serial number of Appliance:

(Optional)

Approximate Rand Value:

(Optional)

Name of Appliance:*

Serial number of Appliance:*

(Optional)

Approximate Rand Value:*

(Optional)

Name of Appliance:*

Serial number of Appliance:*

(Optional)

Approximate Rand Value:*

(Optional)

Name of Appliance:

Serial number of Appliance:

(Optional)

Approximate Rand Value:

(Optional)

Name of Appliance:

Serial number of Appliance:

(Optional)

Approximate Rand Value:

(Optional)

Name of Appliance:

Serial number of Appliance:

(Optional)

Approximate Rand Value:

(Optional)

Name of Appliance:*

Serial number of Appliance:*

(Optional)

Approximate Rand Value:*

(Optional)

Name of Appliance:

Serial number of Appliance:

(Optional)

Approximate Rand Value:

(Optional)

Name of Appliance:

Serial number of Appliance:

(Optional)

Approximate Rand Value:

(Optional)

Name of Appliance:

Serial number of Appliance:

(Optional)

Approximate Rand Value:

(Optional)

Name of Appliance:*

Serial number of Appliance:*

(Optional)

Approximate Rand Value:*

(Optional)

Name of Appliance:

Serial number of Appliance:

(Optional)

Approximate Rand Value:

(Optional)

Name of Appliance:

Serial number of Appliance:

(Optional)

Approximate Rand Value:

(Optional)

Name of Appliance:

Serial number of Appliance:

(Optional)

Approximate Rand Value:

(Optional)

Name of Appliance:*

Serial number of Appliance:*

(Optional)

Approximate Rand Value:*

(Optional)

Name of Appliance:*

Serial number of Appliance:*

(Optional)

Approximate Rand Value:*

(Optional)

Name of Appliance:*

Serial number of Appliance:*

(Optional)

Approximate Rand Value:*

(Optional)

Name of Appliance:*

Serial number of Appliance:*

(Optional)

Approximate Rand Value:*

(Optional)

Name of Appliance:

Serial number of Appliance:

(Optional)

Approximate Rand Value:

(Optional)

Name of Appliance:

Serial number of Appliance:

(Optional)

Approximate Rand Value:

(Optional)

Name of Appliance:

Serial number of Appliance:

(Optional)

Approximate Rand Value:

(Optional)

Name of Appliance:

Serial number of Appliance:

(Optional)

Approximate Rand Value:

(Optional)

Name of Appliance:

Serial number of Appliance:

(Optional)

Approximate Rand Value:

(Optional)

Name of Appliance:

Serial number of Appliance:

(Optional)

Approximate Rand Value:

(Optional)

Name of Appliance:

Serial number of Appliance:

(Optional)

Approximate Rand Value:

(Optional)

Name of Appliance:

Serial number of Appliance:

(Optional)

Approximate Rand Value:

(Optional)

Name of Appliance:

Serial number of Appliance:

(Optional)

Approximate Rand Value:

(Optional)

Name of Appliance:

Serial number of Appliance:

(Optional)

Approximate Rand Value:

(Optional)

Name of Appliance:

Serial number of Appliance:

(Optional)

Approximate Rand Value:

(Optional)

Name of Appliance:*

Serial number of Appliance:*

(Optional)

Approximate Rand Value:*

(Optional)

Name of Appliance:

Serial number of Appliance:

(Optional)

Approximate Rand Value:

(Optional)

Name of Appliance:

Serial number of Appliance:

(Optional)

Approximate Rand Value:

(Optional)

Name of Appliance:

Serial number of Appliance:

(Optional)

Approximate Rand Value:

(Optional)

Name of Appliance:

Serial number of Appliance:

(Optional)

Approximate Rand Value:

(Optional)

Name of Appliance:

Serial number of Appliance:

(Optional)

Approximate Rand Value:

(Optional)

Name of Appliance:

Serial number of Appliance:

(Optional)

Approximate Rand Value:

(Optional)

Name of Appliance:

Serial number of Appliance:

(Optional)

Approximate Rand Value:

(Optional)

Consent

I consent to the processing of my personal information in accordance with the Popi Act

I consent to be bound by the Privacy Policy

I have read and understood the High Surge Warranty Agreement

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Personal Details

Switched Product Details

Consent

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