Customer Property Claim Form
Transcription
Customer Property Claim Form
Customer Property Claim Form Please accept our sincere apologies for the inconvenience you have been caused by the delay of your checked property. To assist us with your claim, please complete and return this form. While our efforts to locate your property continue, it is of the utmost importance to promptly complete this claim form and return it to us as soon as possible. The most intensive phase of tracing is based on the information provided on this claim form. For domestic carriage, in the event you fail to return the completed claim form within 45 days, no action shall lie against United Airlines. The claim form should be completed in its entirety with a detailed description of each individual item contained within the bag(s), or the items missing from the baggage, including signatures from all persons impacted. If your claim involves more than one bag, please itemize each bag and its contents separately. The accuracy of the information you provide enhances our ability to locate your property through our tracing efforts. Failure to include requested information may affect the processing of your claim. In addition, please include the following items in addition to this signed form to assist in processing your claim: • Customer copy of the ticket, or ticket receipt • Original proof of purchase for items valued at $100 USD or higher • Baggage claim checks • Excess value receipt, if excess value was declared at check in • For interim expense reimbursement, receipts are required for all items purchased • International ACH/Wire transfer customers, please include your banking information associated with your country's regulations • Clear copy of driver’s license or other government issued photo ID for each person asserting a claim Important: Please retain copies of all documents you send to us, for your records. Notice of Baggage Liability Limits For domestic travel between points within the United States (except for domestic portions of international journeys), United’s liability for loss of, damage to, or delay in delivery of a passenger’s checked baggage is limited to $3,500 per ticketed passenger, unless a higher value is declared in advance and appropriate charges are paid. In accordance with 14 CFR Part 382, the above limit of liability does not apply for loss, damage or delay of wheelchairs or other assistive devices. Excess value may not be declared on certain types of articles. United assumes no liability for high value, fragile, or perishable items carried in connection with domestic travel. For a complete list of excluded items, see the terms in our Contract of Carriage or at our website, united.com. For international travel to which the Montreal Convention applies, liability for loss, delay, or damage is limited to 1,131 SDR per passenger for baggage, whether checked or unchecked. Exchange rates are available at www.IMF.org. For international travel to which the Warsaw Convention applies, liability for loss, delay, or damage to baggage is limited to $20 per kilogram (approximately $9.07 per pound) up to $640, and $400 per passenger for unchecked baggage. 1 of 3 limited toat1,131 SDR per passenger for baggage, whether checked or unchecked. Exchange rates are available www.IMF.org. available at www.IMF.org. Type of Claim: Damage Loss Pilferage Customer Property Claim Form Interim Type of Claim: Damage Interim Loss Pilferage Personal and Flight Informa on Personal and information, please type orand print legibly Personal Flight Informa on Please Type or Print Legibly Type of Claim: Damage Interim Loss Pilferage Please Type or Print Legibly Reference Number __________________Baggage ClaimClaim CheckCheck Numbers______________________ File File reference number Baggage Nos. File Reference Number __________________Baggage Claim Check Numbers______________________ Name Mr. Name Mrs. Mr. Miss Mrs. Home Address Miss Home Address Last Last First First MI MI Home Phone Area Code Home Phone Area Code City City Business Phone Areas Code Business Phone Areas Code ( ) (Occupa )on ( ) (Employed) By Occupa on Employed By Business Street Address Business Street Address State/Province State/Province E-Mail Address E-Mail Address Zip/Postal Code Zip/Postal Code Total Bags Checked Total Bags Checked Total Bags Lost Total Bags Lost City/State/Province City/State/Province Country Country Zip/Postal Code Zip/Postal Code Country Country Number of Passengers Travelling Number of Passengers Travelling MileagePlus or Frequent Flyer Number/Airline MileagePlus or Frequent Flyer Number/Airline When and where Was your last seen? When andbag where Was your bag last seen? Did you declare and Yes Yes Did declarevalue? and pay you for higher Yes Yes No Value: $_________ pay for higher value? No Amt: $_________ No Value: Was your bag(s) Yes If yes, were you $_________ Yes No rerouted given different Yes If yes, awere you Yes Was youror bag(s) rerouted given a different recheckedorenroute? No claim check? No rechecked No claim Atcheck? what UA office did youNo report Did you a enroute? empt to Yes your loss? At what UA office did you report claim baggage asto Yes Did you a empt your loss? claim baggage as soon as you arrived? No soon as you arrived? No Have you or members of your household ever filed a claim before Did you pay checked bagyou service Did pay charges? checked bag service charges? Amt: $_________ Haveone youwith or members of your ever filed a claim before this any airline(s) for household baggage loss, damage, or pilferage? this one with any airline(s) for baggage loss, damage, or pilferage? Complete itinerary From From To To Where did you check your baggage? Where did you check your baggage? Ticket Counter________ Curbside_______ Other_________ Ticket Counter________ Curbside_______ Reason for Reroute Other_________ City and Airline who handled ngAirline who handled rerou City and rerou ng Reason for Reroute Has loss been reported to another airline? Has Yes loss been reported No to another airline? Yes No airline and city where reported: If yes, please give If yes, please give airline and city where reported: Yes If yes, Airline(s)__________________________________ Yes If yes, Airline(s)__________________________________ No Date(s)__________________________________ No Date(s)__________________________________ Complete I nerary Complete I nerary Airline Airline Flight # Flight # Date Date Cer fica on and Understanding Cer fica on and Understanding The United States Post Office has inves ga ve jurisdic on under federal laws rela ng to sending false or ga ve jurisdic on under federal lawsbyrela ng to sending The Unitedclaims States through Post Office invesStates fraudulent thehas United mails. Any such claims received United Airlines arefalse or The fraudulent United States Post has investigative jurisdiction under federal laws relating to sending false claims through the United States mails. Any such claims received by United Airlines are reported toclaims US Postal authori or fraudulent through thees. United States mail. Any such claims received by United Airlines are reported to US Postal authori es. reported to US Postal authorities. I do hereby promise the foregoing statement and those on all accompanying forms and supporting documents to be accurate, complete, true and I hereby make a claim against United Airlines in the amount of $ for loss occurring on , 20 . Requires signature of each customer claiming lost property. Customer Signature Date Customer Signature Date Customer Signature Date Customer Signature Date 2 of 3 Customer Signature* Date , 20 . *Requires signature Claim of each customer Customer Property Form claiming lost property. Baggage Descrip on and Contents Lis ng Baggage description and contents listing List contents separately if more than one bag Qty 1 Type of Bag Color of Bag Manufacturer Date Purchased Original Cost Ini als, Marks, Labels, or other Exterior Iden fica on. List name of any person(s) which may be on documents, papers, etc. Descrip on of contents: If claim is for more than 1 customer, please indicate ownership of items. Gender: M= Male, F= Female, CH=Child, INF= infant (0-3 yrs.) Ar cle/Item Shirt Size XL Gender M, F, CH, INF M If addi onal space is needed, please a Descrip on, Color, Material, Brand Label Where Purchased Date Purchased Red button up, cotton, Polo Dillard May, 2010 $65.00 ch separate paper with same data as above IncludeInclude the following items with your claim the following items with your claim Total value of bag and contents Reminders cketfor receipts each person involved in loss this loss • ticket Passenger • Passenger receipts each for person involved in this Baggage claim checks • Baggage •claim checks • Excess value receipt, if applicable • Excess value receipt, if applicable • Interim Expense Reimbursement receipts • Interim Expense Reimbursement receipts • Copy of driver’s license or other government issued photo ID for each person in the claim Include original proof of purchase for items valued at $100 or higher Mail to: Email to: United Airlines, Inc. [email protected] Baggage Resolution Service Center 611 Lockhaven Drive Fax to: Houston, TX 77073 1-281-553-1484 If you have any questions, call the Baggage Resolution Service Center at 1-800-335-2247. 3 of 3 Original Cost