Purchase Protection Claim Form Claim Number (required) Instructions: Please complete and sign the Claim Form and send it along with any other requested documentation to the address or fax number above. If you do not have a claim number please contact Us at the number provided above for further instructions. CARD MEMBER INFORMATION American Express Card Account Number used to purchase the item: PURCHASE INFORMATION Item: Manufacturer: Model: Color/Size/Material: Merchant:_ Date of Purchase: Item Amount: Charge Amount: Item: Manufacturer: Model: Color/Size/Material: Merchant:_ Date of Purchase: Item Amount: Charge Amount: Card Member s Name: Address: City: State: Zip: Primary Phone Number: Email: LOSS INFORMATION Type of Loss: Accidental Damage Theft Date of Loss: City, State and Country where loss occurred: Please describe in detail your loss: Lost INSURANCE INFORMATION Do you have a primary homeowner s, renters, condo owner, or business insurance policy? Yes No If yes, please provide the following information: Insurance Company Name: Policy Number/Claim Number: Agents/Adjuster s Telephone Number: Deductible Amount:
ADDITIONAL INFORMATION There are some products and items not covered under this program including, but not limited to, the following: Travelers checks, tickets of any kind, negotiable instruments (including, but not limited to, gift certificates, gift cards and gift checks), cash or its equivalent; animals or living plants; rare stamps or coins; consumable or perishable items with limited life spans (including, but not limited to, perfume, light bulbs, batteries); antique or previously owned items; motorized vehicles and watercraft, aircraft, and motorcycles or their motors, equipment, parts or accessories; stolen or damaged property consisting of articles in a pair or set. Coverage will be limited to no more than the value of any particular part or parts, unless the articles are unusable individually and cannot be replaced individually, regardless of any special value they may have had as part of a set or collection; {items purchased for resale, professional, or commercial use; permanent household and/or business fixtures, including, but not limited to, carpeting, flooring and/or tile; business fixtures, including, but not limited to, air conditioners, refrigerators, heaters; and hospital, medical and dental equipment and devices.} The language between the brackets does not apply to eligible Corporate or Business Card Accounts. There are some Occurrences not covered under this program including, but not limited to, the following: War or any act of war, whether declared or undeclared; any activity directly related to and occurring while in the service of any armed military force of any nation state recognized by the United Nations; participation in a riot, civil disturbance, protest or insurrection; violation of a criminal law, offense or infraction; natural disasters, including, but not limited to, hurricanes, floods, tornados, earthquakes or any other event in the course of nature, that occurs at the same time or in separate instances; fraud or abuse or illegal activity of any kind by the Card Member; confiscation by any governmental authority, public authority, or customs official; negligent failure of a duty to care by any third party in whose possession the property purchased by a Card Member has been temporarily placed; not being reasonably safeguarded by You; theft from baggage not carried by hand and under Your personal supervision or under the supervision of a traveling companion known by You; damage through alteration (including, but not limited to, cutting, sawing and shaping); normal wear and tear, inherent product defect or manufacturer s defects or normal course of play; damage or theft while under the care and control of a common carrier; food spoilage; or leaving property at an unoccupied construction site. PLEASE READ THE INFORMATION BELOW AND SIGN THIS FORM PRIOR TO SUBMISSION. I UNDERSTAND THAT ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURANCE COMPANY, FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF INSURANCE FRAUD. I HAVE READ AND UNDERSTAND THE STATE/TERRITORY FRAUD WARNING THAT IS APPLICABLE TO ME, ON THE FOLLOWING PAGES. THE CLAIM INFORMATION STATED ABOVE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. I UNDERSTAND THAT THE CLAIM FORM MUST BE COMPLETED AND THAT ALL REQUIRED DOCUMENTATION MUST BE FILED AND SUBMITTED BEFORE ANY CLAIM UNDER THE PLAN CAN BE PROCESSED AND PAID. Card Member Signature: Date:
THE FOLLOWING STATES/TERRITORIES REQUIRE NOTICE ON THE FOLLOWING FRAUD DISCLOSURES: Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines, or confinement in prison, or any combination thereof. Alaska: 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. Arizona: 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. Arkansas: 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. California: For your protection California law requires the following to appear on this form: Any person who knowingly presents 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. Colorado: 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 may 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. Delaware: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony. District of Columbia: 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.
Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony of the third degree. Idaho: 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. Indiana: 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. Kentucky: 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. Louisiana: 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. Maine: 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 denial of insurance benefits. Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Minnesota: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. New Hampshire: 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. New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. New Mexico: 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.
New York: Any person who knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance company, 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 value of the subject motor vehicle or stated claim for each violation. Ohio: Any person who, with 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. Oklahoma: 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. Pennsylvania: 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. Puerto Rico: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years. Rhode Island: 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. Tennessee: 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. Texas: 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.
Virginia: 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. Washington: 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. West Virginia: 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. All Other States/Territories: Any person who knowingly and with intent to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is guilty of insurance fraud. Purchase Protection is underwritten by, Administrative Office, Phoenix, AZ under Policy AX0951, Policy AX0952, Policy AX0956, or Policy PP-IND. For residents of GU and MP, the Plan is underwritten by Tokio Marine Pacific Insurance Limited, Hagatna, Guam under Policy CRCB000000105. This benefit is not available to residents of American Samoa, Federated States of Micronesia, Marshall Islands, Palau and the US Minor Outlying Islands. Coverage is determined by the terms, conditions, and exclusions of the Policies applicable to your Card and is subject to change with notice. This document does not supplement or replace the Policy. Shipping and handling costs for the purchase will not be refunded. Certain purchases are not covered, e.g. consumable and perishable items, motorized vehicles and their parts or accessories, and items damaged partially or entirely by natural disaster or normal wear and tear. Other important exclusions apply. You will only be reimbursed for the amount charged to your eligible Card; coverage is limited per occurrence and per Card Member account per calendar year. You may be required to send the purchased item to us, in which case we will reimburse you for shipping cost. To be eligible for claim payment, your account must be in good standing on the eligible card that maintains the original charge. This product provides secondary coverage. This means it pays eligible benefits not paid by any primary insurance that you have. For full Terms and Conditions, see americanexpress.com/ppterms, Consumer Centurion full Terms and Conditions, see americanexpress.com/centurionppterms and Business Centurion full Terms and Conditions, see americanexpress.com/businesscenturionppterms.