Corporate Travel Insurance Claim Form Page 3
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5Section C. Luggage / Personal Effects / Delayed Luggage Claim
THE FOLLOWING ITEMS MUST BE INCLUDED WITH THIS CLAIM*
1. Proof of ownership of the items claimed (ie. tax invoices, receipts, or credit card/bank statements proving purchase of the item/s).
2. Report made to the Transport Provider/ Police/Hotel or other appropriate Authority.
Give full details of how losses, damage or thefts occurred: (Detail each event)
Date loss/damage occurred
/
/
Time
am/pm
Location/Country
Date loss/damage reported
/
/
Time
am/pm
Location/Country
Loss/damage reported to – (Police, Airline or other Authority) Name
Name
Were items lost/damaged by Carrier? (e.g. Airline)
Yes
No
Have you lodged a claim or complaint against any Carrier/Airline or other Authority or against any individual responsible for the loss or damage to
your property? If Yes, please provide details in the table below and attach copies of correspondence. If No, you should proceed to claim with your
Carrier/Airline before submitting your claim to Allianz Global Assistance.
NOTE: The 1999 Montreal Convention imposes a liability upon Airlines and you should claim from them first.
Carrier
Claim no.
What action was taken to recover lost items?
Are any of the items covered by other insurance?
Yes
No
If Yes – Which company
Policy Number
Were all the missing articles owned by you?
Yes
No
If not, give details
Original
Original
Amount
Proof of
Full Details of Articles Claimed
Store Purchased
Country Purchased
Date of
Purchase
Claimed
Purchase
Purchase
Price
(NZD)
Attached?
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