Baggage Protection Baggage Delay HOW TO FILE A CLAIM
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1 Baggage Protection Baggage Delay HOW TO FILE A CLAIM 1. Complete all items on the attached claim form. 2. Attach the following documents (as applicable): Copy of payment or denial from common carrier (e.g., airline, railroad, cruise ship, bus, etc.) Copy of payment or denial from Homeowner s, Renter s or any other insurance providing coverage for this loss Copy of all receipts or estimates for all property lost or damaged Copy of receipts for all expenses incurred as a result of loss (Baggage Delay only) 3. Please upload the completed and signed claim form and all required documents to myclaimsagent.com or mail to: Claim Benefit Services P.O. Box 4090 Atlanta, GA If you choose to mail your documents, please retain a copy of all materials for your records. YOU WILL BE CONTACTED BY A CLAIM ADJUSTER IF ADDITIONAL INFORMATION OR DOCUMENTATION IS REQUIRED. IF YOU HAVE ANY CLAIM RELATED QUESTIONS PLEASE CALL CRAWFORD AT P.O. Box 4090 Atlanta, GA (855)
2 INSURED INFORMATION Baggage Protection Baggage Delay Insured s Statement (Please print Attach separate sheet if additional space required) Insured s Name Insured s Address Phone No. (H) Phone No. (W) CLAIM INFORMATION Date of delay / / Time of day a.m. p.m. Please describe in detail where and how the delay occurred: Please describe in detail the nature and extent of the delay: Did the delay occur while the insured s property was on or in the custody of a common carrier (e.g., railroad, airline, cruise ship, bus, taxi, etc.)? If yes, please complete the following: Name of carrier: Flight/trip/tour number: Did you contact the Carrier upon noticing that your bag(s) had not arrived on schedule? If yes, please identify where, when and to whom (name and title) delay was reported and case number: Please list your expenses for the essential items 1 purchased due to the delay in baggage: Description Date/place of purchase Amount Claimed ( 1 Attach bills of sale, receipts or estimates) 2
3 Are any claimed items used in your business, occupation or profession? If yes, identify the item(s) by * above. AUTHORIZATION I authorize any insurance company, any travel organization or agency, airline carrier, cruise line, tour operator, rental agency, hotel, motel or similar entity providing lodging on a rental/lease basis or any other person who may have knowledge regarding this claim to release any information requested regarding this claim and the loss reported. I understand this information will be used by the Crawford & Company, or its authorized representatives, for the purpose of evaluating and determining coverage for this claim. I know I have a right to receive a copy of this authorization upon request and agree that a photographic or facsimile copy of this authorization is as valid as the original. I agree that this authorization shall be valid for the duration of this claim. I understand that any person who knowingly and with intent to defraud or deceive any insurance company files a claim containing any materially false, incomplete or misleading information may be subject to prosecution for insurance fraud. Signed (Insured or authorized person) Date / / 3
4 IMPORTANT NOTICE Notice to Alaska Claimants: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law. Notice to Arizona Claimants: For your protection, Arizona law requires the following statement to appear on this form: Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. Notice to Arkansas Claimants: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Notice to California Claimants: For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Notice to Colorado Claimants: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties many include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. Notice to Delaware Claimants: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement or claim containing any false, incomplete, or misleading information is guilty of a felony. Notice to District of Columbia Claimants: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. Notice to Florida Claimants: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information, is guilty of a felony of the third degree. Notice to Idaho Claimants: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement containing any false, incomplete, or misleading information, is guilty of a felony. Notice to Indiana Claimants: A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony. Notice to Kentucky Claimants: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Notice to Maine Claimants: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. Notice to Maryland Claimants: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. 4
5 Notice to Minnesota Claimants: A person who submits an application or files a claim with intent to defraud or helps commits a fraud against an insurer is guilty of a crime. Notice to New Hampshire Claimants: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20. Notice to New Jersey Claimants: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. Notice to New Mexico Claimants: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. Notice to New York Claimants: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Notice to Ohio Claimants: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. Notice to Oklahoma Claimants: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Notice to Oregon Claimants: Any person who, knowingly and with intent to defraud an insurance company or other person, submits an application or files a claim for insurance that contains any materially false information relating to an insurance company s acceptance of risk, or conceals for the purpose of misleading, information concerning any fact material to an insurance company s acceptance of risk, may be guilty of a fraudulent act, which is a crime. Notice to Pennsylvania Claimants: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Notice to Rhode Island Claimants: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Notice to Virginia Claimants: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. Notice to Claimants in all other states: Any person who knowingly and with intent to defraud or deceive any insurance company files a claim containing any materially false, incomplete or misleading information may be subject to prosecution for insurance fraud. 5
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Owners / Contractors Protective Liability Application All questions must be answered in full. Application must be signed and dated by the Proposed Policyholder or their Authorized Representative NAME AND
APPLICATION FOR A FINANCIAL INSTITUTION BOND, STANDARD FORM NO. 15 FOR MORTGAGE BANKERS AND FINANCE COMPANIES
This form must be completed for each new bond and at each premium anniversary. If more space is needed to answer any of the questions contained herein, attach additional sheets. Application is hereby made
TRIP CANCELLATION OR TRIP INTERRUPTION MEDICAL CLAIM FORM
Claims Administration Office for Transamerica Casualty Insurance Travelex Claims 4600 Witmer Industrial Estates, Suite 6 Niagara Falls, NY 14305 Telephone: 1-888-526-0260 Fax: 1-877-367-2496 TRIP CANCELLATION
Hospital Confinement/Outpatient Surgery Claim
FAX this direction If your name has changed, attach a copy of your driver s license or other legal documentation. Hospital Confinement/Outpatient Surgery Claim FAX this form: 1-800-880-9325 Or mail: P.O.
6. Does Applicant encrypt all sensitive and Personally Identifiable Information? Yes No If yes, give details:
Name of Insurance Company to which Application is made (herein called the Insurer ) CORPORATE IDENTITY PROTECTION NOTICE: AMOUNTS INCURRED FOR DEFENSE COSTS, ADMINISTRATIVE EXPENSES, NOTIFICATION COSTS,
SmartPro Property Managers E&O Application
NOTICE: THIS APPLICATION IS FOR CLAIMS MADE AND REPORTED COVERAGE, WHICH APPLIES ONLY TO "CLAIMS" FIRST MADE AND REPORTED IN WRITING DURING THE "POLICY PERIOD," OR ANY EXTENDED REPORTING PERIOD. THE LIMIT
Primary Commercial Liability Insurance Application
Name of Insured:(Attach separate sheet if necessary) Address of Insured: Provide names of any subsidiaries or affiliated company(s) to be covered: 1. 2. 3. List all additional insureds to be named with
DISABILITY CLAIM FORM
ACE American Insurance Company PROOF OF LOSS Mail to: ACE American Insurance Company Name of Group: UNIVERSITY OF CALIFORNIA P.O. Box 15417 Wilmington, DE 19850 800-336-0627 or 302-476-6194 Policy Number:
St. Paul Fire and Marine Insurance Company GENERAL INFORMATION
INTERNATIONAL INSURANCE APPLICATION St. Paul Fire and Marine Insurance Company GENERAL INFORMATION Named Insured Effective Date Mailing Address (Street, City, State, Zip Code) Website: Business of Insured:
ERRORS AND OMISSIONS INSURANCE SUPPLEMENTAL APPLICATION AUCTIONEERS ERRORS AND OMISSIONS
ERRORS AND OMISSIONS INSURANCE SUPPLEMENTAL APPLICATION AUCTIONEERS ERRORS AND OMISSIONS 1. Name and Address of Applicant: (Please include DBA s/subsidiaries, etc.) 2. Employee Information: Indicate Numbers:
Malpractice Insurance For International Board Certified Lactation Consultants
Malpractice Insurance For International Board Certified Lactation Consultants 1) Please print a copy of this application to your desktop printer. 2) Complete this hard copy by hand, answering all questions
HEATING, VENTILATION AND AIR CONDITIONING CONTRACTORS GENERAL LIABILITY APPLICATION
HEATING, VENTILATION AND AIR CONDITIONING CONTRACTORS GENERAL LIABILITY APPLICATION Please note: This application is intended to be used for HVAC contractors with under $1,000,000 in receipts. On accounts
APPLICATION FOR BROAD FORM DIRECTORS AND OFFICERS LIABILITY INSURANCE
Monroe Insurance Brokerage, Inc. Home Office M o n t e r e y, C a l i f o r n i a 9 3 9 4 0 APPLICATION FOR BROAD FORM DIRECTORS AND OFFICERS LIABILITY INSURANCE NOTICE: THE POLICY FOR WHICH THIS APPLICATION
Reassessment Information Form. Attachment C
REASSESSMENT INFORMATION FORM Attachment C Instructions: A. Claimant Statement: Provide an update of certain personal information as indicated in this section. B. Employment Statement: Provide details
On behalf of MetLife, please accept our sincere condolences during this difficult time.
U.S. Life Insurance Claims Metropolitan Life Insurance Company Metropolitan Tower Life Insurance Company New England Life Insurance Company MetLife Insurance Company USA First MetLife Investors Insurance