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Baggage Claim Form
SECTION A - CONTACT INFORMATION
Please choose one of the following:

BAGGAGE DELAY □ LOST BAGGAGE □ DAMAGED BAGGAGE □ STOLEN BAGGAGE □ HOTEL BURGLARY □
Name of insured Date of birth
FIRST LAST MM / DD / YYYY

Home Telephone Work Telephone

Home Address City

State/Jurisdiction Postal/ Zip Code Email Address

Mailing Address City

State/Jurisdiction Postal/ Zip Code

Preferred method of contact: Mail □ Email □ Home Phone □ Work Phone □

SECTION B - PLAN INFORMATION

Confirmation/ Policy ID #
Booking #
Date of departure Date of Return
MM / DD / YYYY MM / DD / YYYY
Original Destination
Travel Agency Name
Initial Deposit Date
Agent’s Name
Agent’s Phone Number
Agent’s Email

SECTION C - PROOF OF LOSS STATEMENT

Where and how did loss, theft, damage or delay occur?

Date of loss, damage or delay

Was the baggage delayed
? Yes No For how long?
Did loss or damage occur while insured property was on or in the custody of common
carrier? (i.e., Airline, Cruise Line, Railroad, etc) Yes No
If Yes, list name of Carrier:

ADMINISTRATIVE CONCEPTS, INC | P.O. BOX 4000 COLLEGEVILLE, PA 19426-9000 | 800-567-3512 1

 Baggage Claim Form
SECTION C - PROOF OF LOSS STATEMENT

Did you complete a report at the time of loss or damage? Yes No

If yes, provide a copy of report and list name and title of person to whom notice was given:

Has a claim been filed against

? carrier Yes No If no, please do this immediately and include confirmation of same.

If yes have you been paid by the carrier? Yes No

Please list amount:

Is there any other insurance that might cover this loss? Yes No
(i.e., Homeowners, Renters, Credit Card, etc.)
If yes, please list the name of company, policy number, Address (City, State, Zip Code)

SECTION D - REQUIRED DOCUMENTS*(a)

1) Baggage & Personal Effects (Damaged, lost or stolen bag and/or property while on your covered trip)
a) Completed claim forms (signed and dated);
b) Police report for theft;
c) Copy of the claim filed with the common carrier (airline, cruise line, etc.) along with their final disposition for the filed claim;
d) Proof of ownership for items claimed (purchase receipt, owner’s manual, etc.);
i) If you do not have receipts, please provide the make/model/brand and approximate date of purchase and purchase price
e) Statement from Hotel/Motel, Airline Carrier or Airport Facility that concerns your lost property;
f) Copy of itinerary.

2) Baggage Delay Claim

a) Completed claim forms (signed and dated);
b) Documentation from the common carrier (airline, cruise line, etc.) confirming the delay and the length of time the luggage was delayed;
c) An itemized copy of the receipts for essential items purchased during the baggage delay;
i)The receipts must provide proof of the following: place of purchase, date of purchase, items purchased
ii)Essential items are defined as "necessary personal effects" (i.e., needed clothing and toiletries that were contained in the bag that was
delayed)
d) Copy of itinerary;
e) Copy of delivery invoice showing charge for delivery (if applicable).
*(a)
We reserve the right to request additional information/ documentation including original receipts as needed to process the claim.

SECTION E - DESCRIPTION OF LOST/ STOLEN/ DAMAGED ITEMS

(If additional space is needed, please attach a separate document with items listed as below)

Item(s): Estimated Value Have you received If so, from How much?
reimbursement? whom?
$ $
$ $
$ $
$ $
$ $

ADMINISTRATIVE CONCEPTS, INC | P.O. BOX 4000 COLLEGEVILLE, PA 19426-9000 | 800-567-3512 2

 Baggage Claim Form

SECTION G - AUTHORIZATION
FAILURE TO SIGN AND DATE MAY DELAY THE REVIEW OF YOUR CLAIM.

FRAUD WARNING: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or
other person, who files a statement of claim containing any false information, or conceals for the purpose of misleading, Information
concerning any fact material thereto, commits a fraudulent insurance act, which may be a crime and may be
subject to criminal prosecution, civil penalties and forfeiture of insurance benefits.

AUTHORIZATION

I AUTHORIZE any insurance company, physician, hospital, and other health care providers, any travel organization or agency, airline
carrier, rental agency, hotel, motel, or similar entity providing lodging on a rental/lease basis or any other person who may have
knowledge regarding this claim, to release any information requested to Administrative Concepts, Inc and/or their affiliate partners
regarding this claim and the loss reported.

By signing this claim form, I certify that all information given above is true and complete to the best of my knowledge.

Signature: ________________________________________ Date Signed: ____/____/_____

Print Name: _______________________________________

You can create a profile and track this and your other Starr claims using the following link:
http://www.acitpa.com

Or, mail the completed and signed claim form and all required documents to:
Administrative Concepts, Inc
P.O. Box 4000
Collegeville, PA 19426-9000
If you choose to mail your documents, please send a copy of your documents and retain the originals for your records. Administrative
Concepts, Inc is unable to return any submitted documents. You will be contacted by a claim adjuster if additional information or
documentation is required.
FAX: 610-293-9299

ADMINISTRATIVE CONCEPTS, INC | P.O. BOX 4000 COLLEGEVILLE, PA 19426-9000 | 800-567-3512 3

 Baggage Claim Form

Fraud Statements
General: 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.
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, Louisiana, Maryland, 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.
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.
Connecticut: This form must be completed in its entirety. Any person who intentionally misrepresents or intentionally fails to disclose any material fact related to a claimed injury
may be guilty of a felony.
Delaware, Idaho, Indiana: 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 or an application containing any false, incomplete or
misleading information is guilty of a felony of the third degree.
Hawaii: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or
imprisonment, or both.
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. 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 a denial of
insurance benefits.
Michigan, North Dakota, South Dakota: Any person who knowingly and with intent to defraud any insurance company or another 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, and
subjects the person to criminal and civil penalties.
Minnesota; A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
Nevada: Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may be guilty of a criminal act
punishable under state or federal law, or both, and may be subject to civil penalties.
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 section 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 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
shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such 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.
Oregon: Any person who makes an intentional misstatement that is material to the risk may be found guilty of insurance fraud by a court of law. 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.
Tennessee, Virginia, Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purposes 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.

ADMINISTRATIVE CONCEPTS, INC | P.O. BOX 4000 COLLEGEVILLE, PA 19426-9000 | 800-567-3512 4