DESTROYED, LOST or STOLEN SECURITY BLOCK POLICY & CLAIM FORM
Amada America, Inc. requires that the destruction, loss or theft of software security block devices (aka, “hardlocks” or “dongles”) be fully documented in the event that such blocks re-surface on site or elsewhere. If asoftware security block device is destroyed, lost or stolen it will be replaced, pursuant to the following Please indicate the nature of your request RMA Cancellation (requires items 1, 2 and 3 as listed below)
Block Replacement (requires items 1, 2, 3 and 4 as listed below)
Required Supporting Documents
Amada is pleased to provide replacement blocks to our customers in the event the software security
block is destroyed, lost or stolen. To facilitate replacement, please submit the required supporting
documentation as indicated 1. Police or fire report - Amada requires a receipt of the police or fire department report or astatement of denial of service from your local police department if they cannot proceed on a report fora destroyed, lost or stolen software security block.
2. Letter from your insurance company - This letter must indicate whether or not your software
security block is covered. If the block is NOT covered, the letter must state that you cannot make aclaim. If it is covered, discuss making a claim for reimbursement with your insurer.
3. Amada Block Policy and Claim Form - This form must me filled out with all required information,signed and dated. All supporting documentation, including a purchase order (for block replacement
requests only), must be submitted with the form in order to begin processing the block request.
4. Purchase order for replacement block at $200* each (required only when requesting blockreplacement).
Additional Insurance Information
We understand that it takes time to acquire the above documents, so Amada will provide a temporary
replacement block, and issue an invoice for the full value of the block that we will replace with terms
based on your current Amada account status. You may provide this invoice to your insurancecompany as evidence of the value of the block.
In the event you do not have insurance coverage, we will replace the block (including the softwarethat the block is licensed to) at a price of $200* each. However, we must have a letter from yourinsurance company stating that the block is not covered. Upon receipt of this letter we will issue acredit for the original invoice and issue a new invoice at the current replacement rate.
If we do not receive a letter from your insurance company indicating that you do not have coverage,
the original invoice will be due and payable. Permanent unlock passwords, if the block permits, will
be provided upon receipt of full payment.
For questions please contact your salesman, or the Amada Software Dept. at (714) 549-0112.
Thank you*Price subject to change without notice
page 1 of 2
Fax to Amada at (714) 443-5036, or email a scanned copy to sworderdesk@amada.com

DESTROYED, LOST or STOLEN SECURITY BLOCK POLICY & CLAIM FORM (cont.)
By filling out, signing below and faxing this form to Amada at (714) 443-5036 (or emailing a scanned
copy to sworderdesk@amada.com), you acknowledge the destruction, loss or theft of the security
block (enter block numbers below) and agree to abide by the terms and conditions of this claim form.
If at any time you, the customer, discover that you in fact have possession of a security block thatwas reported as destroyed, lost or stolen, you must notify Amada immediately. If you fail to notify
Amada, you will be required to pay the list price* for the block.

RMA Reference Number(s)If you selected RMA Cancellation on page 1 as the nature of your request, please enter the RMA Reference number(s) -Software Information
Software Block Type(s) -Serial Number(s) -Check one Destroyed

Lost

StolenDestroyed

Lost

StolenDestroyed

Lost

StolenDestroyed

Lost

StolenDestroyed

Lost

StolenCustomer Information
Contact Name

EmailCompany Name

Customer Signature

DateTelephone

DO NOT WRITE IN THIS BOX. For Amada internal use only.

_____________________________________________________________

Amada Software Manager

Date

Request Approved -□ Yes □ No

Documents provided by customer -□ Police/Fire Report □ Proof of Ins. □ Purchase Order □ Other

page 2 of 2
Fax to Amada at (714) 443-5036, or email a scanned copy to sworderdesk@amada.com