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.
brc-claimsdesk@united.com
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.
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Original
Cost