Customer

Please enter all required information about the damage/fault, device detail and your contact information.

Attach a copy of the original invoice for the device and a photo of the damage. The files can be either JPG or PDF format.

* Required input fields

Choose invoice scan or photo file*:

Choose damage photo file:

Choose additional photo file:

Salutation:

Title:

Firstname*:

Surname*:

Street*:

ZIP code*:

City*:

Country*:

Phone:

Email*:

Email again
for control*:

Bank-IBAN:

Inovice number for device purchase*:

Date of device purchase*:

Dealer*:

Dealer ZIP:

Manufacturer*:

Type and model of device*:

Device name*:

Serial number / IMEI*:

Device retail price
from invoice*:

Insurance policy number
(if existent):

Date of damage*:

Time*:

Where did the damage occur?*:

Who caused the damage?*:

How did the damage happen?*:

Description of damage*:

Check image:

Please enter text from check image*:

I am 16 years or older and agree to the processing of my voluntarily entered data according to the Aqilo Data Protection (review at Datenschutzerklärung).

Please review your input for correctness, than press send to submit the data

You will receive your claim number and confirmation email on the next page

current time:

Damage/Fault claim form

Please enter all required information about the damage/fault, device detail and your contact information.

Attach a copy of the original invoice for the device and a photo of the damage. The files can be either JPG or PDF format.