INSURANCE CLAIM COPAYMENT AGREEMENT

Acknowledgment of  during an ESCO® Claim

After the original warranty on your hearing instrument expires, we recommend ESCO for loss & damage coverage.  and ESCO work together to provide you peace of mind against the unexpected financial setback of a lost or damaged hearing instrument.

Under this agreement if your hearing instrument is lost, damaged, or malfunctions  will help you submit a claim to ESCO. After the claim is authorized,  will order the necessary repairs or replacement. All repairs or replacements of your hearing instrument will be like brand, type, and quality.

Hearing instruments are sophisticated electronic devices requiring specialized professional services only your practitioner can provide.

I understand, if I file an ESCO claim,  will charge the following for their time and services.

• ESCO Loss Claim: See Practitioner
• ESCO Damage: See Practitioner
• ESCO Repair Claim: See Practitioner
• Office Visit while assisting with an ESCO Claim: See Practitioner