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Blaze Customer Promise Claim Form
Submission Date
Customer Information
Account First Name
*
Account Last Name
*
Mobile Contact Number
Email Address
*
Confirm Email Address
*
Blaze Account/Main Phone Number
*
Claim Information
Blaze Promise
*
Which customer promise are you claiming against?
Application Acknowledgment
Installation Time
Installation Schedule
Installation Completion
Blaze Speed <90% at Installation
Solving Billing Issue <5 Business Days
Solving Service Issue <10 Business Days
Application Reference #
*
Bill Query Submission Date
*
What date did you first file this billing query?
Month
Month
Jan
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Day
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Year
Year
2020
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2022
2023
Service Query Submission Date
*
What date did you first file this service query?
Month
Month
Jan
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Day
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Year
Year
2020
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2022
2023
Bill Query Completion Date
What date was this bill query completed?
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
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Year
Year
2020
2021
2022
2023
Service Query Completion Date
What date was this service query completed?
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
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31
Year
Year
2020
2021
2022
2023
Supporting Information
*
Please provide a summary of the basis for your claim
Supporting Docs
Upload documents supporting your claim
Files must be less than
4 MB
.
Allowed file types:
gif jpg jpeg png pdf doc docx
.
Supporting Docs
Upload documents supporting your claim
Files must be less than
4 MB
.
Allowed file types:
gif jpg jpeg png pdf doc docx
.
Government ID
*
ID of account owner
Files must be less than
2 MB
.
Allowed file types:
gif jpg jpeg png
.