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agreement? Replaced   Yes  No $ Original Purchase Price: $ Electronic Item: Brand: Model Number: Indicate if item was repaired or replaced Repair/Replacement Costs: Repaired  Serial Number: Is item covered by another warranty or extended service agreement? Replaced   Yes  No $ SECTION D Total amount for which claim is being made $ Will you/have you filed a claim, for any of the listed items, with your insurance company and/or any warranty company?  Yes  N.

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