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| Member's
First Name: |
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| Member's
Surname: |
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Atlas
Membership number** See below
**You must first become an Atlas member |
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| Your Email
address |
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| First Name of
Person whose phone is to be insured |
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| Surname of
Person to be insured |
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| Relationship
to Atlas member |
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| Mobile Phone
number of phone to be insured |
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| Make of
Mobile Phone: |
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| Model number: |
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Serial number
of your phone
(on the case under the battery) |
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Your unique
IMEI number
(press *#06#
on the keypad) |
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| Total $ value
of your plan (the total number of months of your plan X the
monthly payment) or the purchase cost of your phone: |
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| Date on which
your contract started or you purchased your phone. dd/mm/yy |
dd/mm/yy |
| Is the phone
to be insured owned or on a plan? |
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| I wish to
pay premiums |
Select one |
| I wish to
insure my Mobile for a period of: (min 12 month max 2 years) |
|
I wish to pay
by:
We have ceased taking credit cards
due to bank charges |
Select one |
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| ** If you are
not a member to sign up for free membership click
here |
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