CAH Claim Form _Personal Property and Money_.doc updated o…

CAH CLAIMS DEPARTMENT
106, Fenchurch Street, London, EC3M 5NB
phone:
+44 (0) 207 956-5000
fax:
+44 (0) 207 956-5922
email:
[email protected]
PERSONAL PROPERTY AND MONEY
(Including Damaged / Delayed / Lost Luggage)
How to Submit a Claim
1. Please complete all sections of the attached claim form as fully as possible;
2. Please attach the following documents:
-
Copy of travel itinerary,
-
Booking Invoice showing trip details and dates,
-
Original airline tickets, or other travel documents,
-
In respect of money claims, currency conversion slips / copy of bank/building society
statements or a letter from your bank confirming withdrawal of funds prior to your trip,
-
Original purchase or replacement receipts to substantiate the amounts being claimed,
-
Airline’s Property Irregularity Report, and air tickets / baggage tags if items damaged or lost
in the custody of the carrier,
-
For cases of theft, a copy of the Police Report,
-
If claiming for damaged items, please provide a written repair estimate from a suitable
supplier,
3. Please ensure your claim form is countersigned by your line manager or HR representative
4. Please send the completed and signed claim form and all required documents to the above
address.
5. Please retain copy of all documentation for your records.
Please note that you will be contacted by a Claims Examiner once these details have been
received.
Information Sheet
Damaged / Delayed / Lost Luggage
CLAIMANT DETAILS
Full Name
Occupation
Home Address
Home Phone
Mobile Phone
Relationship to Insured Company if not Employee
EMPLOYER DETAILS
Company
Phone
Company Address
Fax
Policy Number
CLAIM DETAILS
Date of Incident
Time of Incident
Location and
Name of Carrier
Has a Claim been
Description of
Incident Details
submitted to Carrier
Carriers Reference
Has any Offer, Payment been made, Details
Has matter been notified to Airline Authorities, Police, Details
For delayed luggage, when it was returned to you
Do you have any other Insurance providing cover for this incident or loss
Yes
No
If yes, please provide us with the name and address of the insurer, and the policy
number:
Was the trip for Business purposes or Personal holiday
BENEFICIARY INFORMATION
To whom should any payment be made?
For Electronic Fund Transfer, please provide your full bank details; Bank Name,
Bank Address, Account No, Sort Code, Swift Code (non-UK Banks) and Name of
Account Holder
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If your luggage was delayed for a period of time, but then returned to you, please complete Section I, indicating any essential replacement clothing or toiletry articles you
purchased during this time. Attach a separate sheet if necessary.
If your luggage was permanently lost, please complete the Section II. If your property was damaged beyond repair, please provide written confirmation of this, original
purchase receipt as well as a replacement quotation from a suitable supplier. Attach a separate sheet if necessary.
SECTION I: ESSENTIAL ITEMS PURCHASED WHILE LUGGAGE WAS MISSING
Description
Date and place purchased
SECTION II : VALUATION OF LOST AND/OR DAMAGED PROPERTY
Original Date and Place of
Description
Purchase
Original Cost
Cost
Damaged or Lost
Replacement Cost or
Estimate
DECLARATIONS
I declare that to the best of my knowledge, the particulars presented herein are true. 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. I also
understand and consent that information herein may be made available to other insurers for underwriting and claims handling purposes and consent to Chubb Insurance
Company of Europe SA seeking information from other insurers to confirm any information presented.
Signed
Date
Insured or Authorised Person
Name
Signed
Date
Line Manager or HR Department
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