Econocheck.ClubChecking.com

Contact Information

First Name:*

Last Name:*

Email Address:*

Phone:*

Address Line 1:*

Address Line 2:

City:*

State:*

Zip:*

Are you an employee of your financial institution?

Job Title:

Device Information

Device Type:*

Device Phone Number:*

Device Model:*

Device Make:*

Wireless Service Carrier:*

Claim Information

Date of Incident:*

The date the damage or theft took place to your device

Type of Incident:*

Description of Incident:*

Required Documentation

Please read the requirements carefully.

Failure to provide the requested documents could result in non-payment of your claim.

Refer to the Guide to Benefit for additional details regarding the Cellular Telephone Protection Benefit.

For questions about claims call 1-866-210-0361.

Wireless Service Billing Statement

The wireless bill for the device claimed is required.

The billing statement must contain:

Information for the billing cycle prior to the date of the incident.
Your name listed on the statement.
The page that lists all phone numbers associated with the wireless cellular plan. It is not necessary to include a log of calls/texts.
All features and services associated with the wireless cellular plan.

Theft/Criminal Action

Claims due to theft or criminal action require a police report. The case number alone is not sufficient. The police report must be filed within 48 hours of the incident.

Damaged Device

Claims for a damaged device require an estimate of repair or repair receipt from an authorized retailer or repair facility.

The repair estimate/receipt must contain the:

Repair facility’s contact information
Cell phone number associated with the device
Explanation of the damage to the device including required repairs
Cost/estimate of repair
Brand/model of the device

Other Coverage?

Coverage under the Cellular Telephone Protection Benefit is in excess of any other coverage you have available.

If you have existing coverage for your mobile device and your claim has not been filed or processed, verification of your deductible amount and a repair estimate or police report, as applicable, is required.
If your claim has been completed, a copy of the claim including the deductible paid to your insurance carrier is required.
If your claim is not covered by your insurance carrier, a letter of denial from the insurance carrier is required.

Acknowledgments

Check boxes to confirm:* The Cellular Telephone Protection Benefit covers personal cellular telephones in the event of theft or damage occurring while your eligible account is active, and your claim was submitted within 60 days of the incident. All required documentation for your claim must be submitted within 90 days of the incident. If additional information is requested, it must be returned within 6 months of the date of the incident.

The Cellular Telephone Protection Benefit does not cover cellular wireless telephones purchased for resale, professional or commercial use. Cellular wireless telephones listed under business wireless plans are not covered as they are utilized for the purpose of conducting professional and/or commercial activities.

The Cellular Telephone Protection Benefit does not cover phones that are lost or “mysteriously disappear”. “Mysterious disappearance” means the vanishing of an item in an unexplained manner where there is absence of evidence of a wrongful act by a person or persons. Please refer to the Guide to Benefit for full details of coverage and exclusions.

By submitting your claim through this online claim form submission portal, you consent to the processing of your claim electronically. If you wish to process your claim in paper format, you may contact the Benefit Administrator at 1-866-210-0361.

The claim information stated above is true and correct to the best of my knowledge and belief. I understand that any material misrepresentation of fact on this claim form automatically voids my claim. I UNDERSTAND THAT THE CLAIM FORM MUST BE COMPLETED AND THAT ALL REQUIRED DOCUMENTATION, POLICE REPORTS, ETC., MUST BE FILED AND SUBMITTED BEFORE ANY CLAIM UNDER THE BENEFIT CAN BE PROCESSED AND PAID. I understand that the Cellular Telephone Protection Guide to Benefit made available to me through this online claim form submission portal includes the terms and conditions for the Cellular Telephone Protection Benefit and that any other information provided to me does not override that document. I understand that my failure to comply with the terms and conditions of the Cellular Telephone Protection Benefit is an action constituting breach of contract and subjects me to legal action. I understand my rights of recovery or remedies for my theft or damage, including any funds I receive for the claim I am submitting, is transferred to the Benefit Administrator to the extent of the amount of the claim payment to me. I waive the right to interpose any defense in any litigation arising out of the claim I have filed. I authorize my financial institution and/or program provider to release to Econocheck Corporation, Benefits Administrator for the Cellular Telephone Protection Benefit, information regarding my account for the processing of this claim. I further authorize the Benefit Administrator to obtain copies of any police, fire, or other investigative reports and information needed to process my claim. In addition, I hereby agree to cooperate with any designated representative of the Cellular Telephone Protection Benefit in the investigation of my claim and provide statements when requested to do so.

By checking this box, I acknowledge that I have read and agree to the terms stated above and I can access the information needed to submit my claim to the Benefit Administrator electronically to my satisfaction. I also confirm that I can access and read the disclosures on this form and that I can print the Guide to Benefit and disclosures on paper or save them to a place where I can print them for future reference and access.

Electronic Signature:*

File a Claim