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your name
address
cIty
state ZIp
10-dIGIt phone
emaIl address
If you provide your email address we will notify you when your claim has been received via email.
GE Appliances takes your privacy seriously. All information you provide shall be held in strict accordance with GE Appliances’ Privacy Policy
(www.geappliances.com/privacy/privacy_policy.htm).
Offer void where prohibited, taxed, or restricted by law. Not transferable or
redeemable for cash. Fraudulent submission of form could result in federal
prosecution for mail fraud under the U.S. Mail Fraud Statutes (18 USC Section
1341 and 1342). This form must be included with your claim. Omission of sales
receipt or any other required infor mation will delay processing. Please allow eight
to ten weeks from the time the form is received for delivery of the prepaid Visa
card. If not received after ten weeks, call 1-866-319-9259, Monday-Friday: 9:00
AM - 9:00 PM EST; Saturday-Sunday: 9:00 AM - 5:00 PM EST.
Cards are issued by Citibank, N.A. pursuant to a license from Visa U.S.A. Inc. and
managed by Citi Prepaid Services. Cards will not have cash access and can be used
everywhere Visa debit cards are accepted. This card is a Visa prepaid card. Each
time you use the card the amount of the transaction will be deducted from the
amount of your available balance. Terms and Conditions apply to the card.
Subject to applicable law, a monthly maintenance fee of $3 (USD) applies, but
is waived for the first six months after the card is issued. No additional fees will
be assessed once the card balance reaches zero. Cards can be used at merchants
that accept Visa debit cards. GE reserves the right to substitute a check of equal
value in lieu of a Visa prepaid card at its sole discretion.
I/we hereby understand and accept the above requirements for receipt of the
prepaid Visa card and I/we represent that all information provided on this
document is accurate and not falsified.
Your Signature _________________________________________________________________________________________ Date ______________________
© 2016 GE Appliances 35429-GE PC83784
Serial Number Model Number
prevIous cooktop:
Serial Number
new Ge applIances cooktop:
Modification Cost