Sears Protection Agreements: Discount Protection



How did you purchase your eligible part?

Receipt Information

* Sales Check #:
* Purchase Date:
* Eligible Part Purchase Price:
* Eligible Product Type:
* Eligible Product Brand:
* Eligible Part Description:

Customer Information

* First Name:
* Last Name:
* Address 1:
   Address 2:
* City:
* State:
* Zip Code:
* Primary Phone #:
   Secondary Phone #:
   E-mail Address: