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End costumer claim upload.

Please scan the invoice and enclosures so that all important data are clearly legible.

Fields marked * need require your input. Scans or fotos must not exceed 3MB.

Choose invoice scan or photo file*

Choose damage photo file*:

Choose additional photo file:

Title

Firstname*

Surname*

Street*

ZIP code*

City*

Country*

Phone

Email*

Email (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 price from invoice*

Insurance policy number (if available)

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