Warranty Registration

By completing this registration form and sending it to us today, we will remind you when your manufacturer's loss and damage coverage is about to expire. At that time, you will be given the opportunity to continue your loss and damage coverage through one of our three programs. Reserve this option to protect your valuable hearing instrument. Complete and send today - we will do the rest.

Please send me a notice to continue my loss and damage coverage for the hearing instrument described below. This coverage will take effect on the expiration date of the manufacturer's warranty for loss and damage coverage.

Contact Info

First Name:

Last Name:

Address 1:

Address 2:

City:

State:

Postal Code:

Phone:

E-mail Address:

Warranty Info

Manufacturer:

Model:

Circuit Options:

Left Serial:

Right Serial:

Expiration Date:

Program Type:

Denotes required fields