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Mtn.co. za LAPTOP INSURANCE CLAIM FORM Theft Cellular Number Lost Damage - Account Number Contact Number Fax Number User Name User ID Number E-mail Address Account Holder Cellular Phone Make Model Laptop Serial No Alpha Numeric digits on the back of the laptop or on packaging of the laptop. Date last used with Modem// Date of Incident// Full Description of Incident EXCESS Lost or stolen or Damaged laptop. I agree to pay the applicable excess of a 1st Claim Excess R500. 00 In respect of Equipment stolen from a locked and protected vehicle an additional excess of 20 of the value of every claim will be charged FOR REPAIRS TO BE AFFECTED THE LAPTOP MUST BE BOOKED WITH THE MANUFACTURE For Theft / Loss Police Station Date Reported to MTN SERVICE PROVIDER // Tel No Case No Note No claim for theft from a vehicle / premises will be accepted without evidence of forcible entry in the form of an approved repair invoice to be submitted with this claim form. Date Reported / / Directors PL Heinamann Chairman KW Pienaar Managing Director Z Bulbulia SL Botha ZNA Cindi RS Dabengwa R Gasant IN Mkhize CWN Molope PF Nhleko RD Nisbet PD Norman AJ Taylor Company Secretary AM Sithole Executive DECLARATION I/ We declare to the best of my/ our knowledge and belief that the above particulars are true and correct and I/ we undertake to render MTN SERVICE PROVIDER every assistance in my/ our power in dealing with the matter. MTN SERVICE PROVIDER PTY LTD Head Office 216 14th Ave Fairland 2195 Private Bag 9955 Cresta 2118 South Africa Tel 83 123 6084 Fax 2711 912 5122 http //www. 00 b 2nd Claim Excess R1000. 00 within a 12 months period c Any subsequent claim within a 12 months period shall carry an excess of R1000. I/ We hereby agree that MTN SERVICE PROVIDER may take over and conduct the prosecution for their own benefit of any claim for indemnity or otherwise and shall have full discretion in the conduct thereof* I the undersigned hereby waive any rights of recourse that I may have against MTN SERVICE PROVIDER relating to the disclosure of the above mentioned information* Should any equipment be recovered after a claim has been submitted this equipment becomes the property of If the laptop is deemed to be beyond economical repair by an approved Repairer all components such the battery and charger must be submitted by the claimant. Claimant Signature Date PLEASE NOTE This claim will take approximately 24 hours when this application is 100 complete with all information verified* MTN Service Provider is an Authorised Financial Service Provider. I/ We hereby agree that MTN SERVICE PROVIDER may take over and conduct the prosecution for their own benefit of any claim for indemnity or otherwise and shall have full discretion in the conduct thereof* I the undersigned hereby waive any rights of recourse that I may have against MTN SERVICE PROVIDER relating to the disclosure of the above mentioned information* Should any equipment be recovered after a claim has been submitted this equipment becomes the property of If the laptop is deemed to be beyond economical repair by an approved Repairer all components such the battery and charger must be submitted by the claimant. Claimant Signature Date PLEASE NOTE This claim will take approximately 24 hours when this application is 100 complete with all information verified* MTN Service Provider is an Authorised Financial Service Provider.

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