Fill - Free fillable Trip Delay Claim Form To be completed by (Trip Preserver online claims) PDF form

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Trip Delay Claim Form To be completed by (Trip Preserver online claims)

Trip Delay

Claim Form

To be completed by the Insured / Guest

Name of Insured / Guest Reservation #

Address Work Phone # Home Phone #

E-mail Address Date of Birth

Scheduled Departure Date Scheduled Return Date Date Delayed (mm/dd/yy)

Name and Address of Property Management Company Phone # Fax #

Name of leaseholder on the rental property and list all guests occupying the property

Please Briey explain your claim:

Is there any other insurance that provides coverage for this loss (homeowners, renters, credit card, other travel insurance)?

If yes, please provide name of insurance company, policy number, and address

Please check the box which applies to your claim

 Additional accommodation and meal expenses

Amount being claimed: ___________________

 Additional Transportation Expenses

Amount being claimed: ___________________

 Prepaid, Unused non-refundable land and water accommodation trip costs

Amount being claimed: ___________________

Please supply the following items based on which box you’ve checked.

3

If delay is due to a common carrier delay, please provide us with written verication from the common carrier as to the cause and

length of your delay. Please include your ight itinerary or ticket copies from your common carrier. If not, provide documentation

verifying the case of delay.

• For additional Accommodation Expenses:

￮ Please provide us with proof of payment for additional accommodations and meal expenses (invoices or receipts and a copy

of your canceled check or credit card statement showing payment for the additional expenses).

• For additional Transportation Expenses:

￮ Please provide us with proof of payment for additional transportation expenses (invoices or receipts and a copy of cancelled

checks or credit card statement showing payment for the additional expenses).

• For pre-paid, unused non-refundable land and water trip costs:

￮ Please provide us with proof of payment for pre-paid, unused non-refundable land and water trip costs (invoices or receipts

and a copy of cancelled checks or credit card statement showing payment for the additional expenses).

3 If claimant is other than leaseholder, please provide a signed written statement from leaseholder listing all guests occupying the

rental property.

Arch-2014

 Yes  No

Claims Department:

Red Sky Claims, C/O Arch Insurance Company

Executive Plaza IV, 11350 McCormick Road, Suite 102, Hunt Valley, MD 21031

Toll Free Phone: (866) 889-7409 | Fax: (443) 279-2901 | E-mail: redsky@archinsurance.com

Any person who knowingly presents a false or fraudulent claim for payment of loss or benet or

knowingly presents false information in an application for insurance is guilty of a crime and may be

subject to nes and connement in prison.

Trip Delay

Claim Form

List all guests occupying the rental property

Guest Name: Claiming trip delay?

 Yes  No

Guest Name: Claiming trip delay?

 Yes  No

Guest Name: Claiming trip delay?

 Yes  No

Guest Name: Claiming trip delay?

 Yes  No

Guest Name: Claiming trip delay?

 Yes  No

Guest Name: Claiming trip delay?

 Yes  No

Guest Name: Claiming trip delay?

 Yes  No

Guest Name: Claiming trip delay?

 Yes  No

Guest Name: Claiming trip delay?

 Yes  No

______________________ Total expenses being claimed

Authorization to Disclose Information

Trip Preserver Product is Underwritten by Arch Insurance Company.

To any medical care provider, medical care facility, insurer, government-sponsored health plan, or employer: I authorize the release of any

medical information about me to Arch Insurance Company, or its authorized representative. This applies to all information about the diag-

nosis, treatment, or prognosis of any illness or injury I now have or have had in the past.

To any insurance company, any travel organization or agency, airline carrier, cruise line, your operator, 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: I authorize the

release any information requested regarding this claim and the loss reported.

The company will use this information to determine if any claim is eligible. Any information obtained will not be released by the Company

except to my primary health insurance carrier (if any) or persons or organizations performing investigation or legal services for the Compa-

ny in connection with my claim. A copy of this authorization shall be considered as eect and valid as the original and shall remain in eect

for one year from the date of authorization.

I certify that the information given by me in support of my claim is true and correct. I understand that any person who knowingly and with

intent to defraud or deceive any insurance company les a claim containing any materially false, incomplete or misleading information

may be subject to prosecution or insurance fraud.

Patient’s or Authorized Representative’s Signature Date

If Authorized Representative, Relationship to Patient

or Legal Designation

Arch-2014

Claims Department:

Red Sky Claims, C/O Arch Insurance Company

Executive Plaza IV, 11350 McCormick Road, Suite 102, Hunt Valley, MD 21031

Toll Free Phone: (866) 889-7409 | Fax: (443) 279-2901 | E-mail: redsky@archinsurance.com

Any person who knowingly presents a false or fraudulent claim for payment of loss or benet or

knowingly presents false information in an application for insurance is guilty of a crime and may be

subject to nes and connement in prison.

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The laws of some states require us to furnish you with the following notices:

WARNING. Any person who knowingly:

Alaska: and with intent to injure, defraud, or deceive an insurance company les a claim containing false, incomplete, or misleading information

may be prosecuted under state law.

Arizona, Arkansas and Rhode Island: presents a false or fraudulent claim for payment of a loss or benet is subject to criminal and civil pen-

alties, or specic to AR and RI: presents false information in an application for insurance is guilty of a crime and may be subject to nes and

connement 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 payment of a loss is guilty of a crime and may be subject to nes and conne-

ment in state prison.

Delaware: and with intent to injure, defraud or deceive an insurer, les a statement of claim containing any false, incomplete or misleading infor-

mation is guilty of a felony.

District of Columbia: 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 nes. In addition, an insurer may deny insurance benets if false information materially related to

a claim was provided by the applicant.

Florida: and with intent to injure, defraud, or deceive any insurance company, les a statement of claim containing any false, incomplete, or

misleading information is guilty of a felony of the third degree.

Idaho and Indiana: and with intent to defraud or deceive any insurance company, les a statement of claim containing any false, incomplete or

misleading information (for Idaho) is guilty of and (for Indiana) commits a felony.

Kentucky, New York, and Pennsylvania: and with intent to defraud any insurance company or other person les an application for insurance,

or les a statement of claim, containing any materially false information or conceals, for the purpose of misleading, information concerning any

material fact thereto commits a fraudulent insurance act, which is a crime, specic to PA: subjects such person to criminal and civil penalties and

specic to NY: shall also be subject to a civil penalty not to exceed ve thousand dollars and the stated value of the claim for each such violation.

Louisiana, New Mexico, Texas and West Virginia: presents a false or fraudulent claim for the payment of a loss (or specic to LA, TX and WV: who

knowingly presents false information on an application for insurance) is guilty of a crime and may be subject to nes and connement in state

prison, (or specic to NM: to civil nes and criminal penalties.)

Maryland: and willfully presents a false or fraudulent claim for payment of loss or benet or who knowingly and willfully presents false informa-

tion in an application for insurance is guilty of a crime and may be subject to nes and connement in prison.

New Jersey: les a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

Ohio: with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits and application or les a claim containing a false

or deceptive statement is guilty of insurance fraud.

Oklahoma: 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: and with intent to defraud any insurance company or other person les an application for insurance or a statement of claim containing

any materially false information or conceals for the purpose of misleading, information concerning any fact material hereto, may be subject to

prosecution for insurance fraud.

Puerto Rico: and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the pre-

sentation of a fraudulent claim for the payment of a loss or any other benet, or presents more than one claim for the same damage or loss, shall

incur a felony and, upon conviction, shall be sanctioned for each violation with the penalty of a ne of not less that ve thousand (5,000) dollars

and not more than ten thousand (10,000) dollars, or a xed term of imprisonment for three (3) years, or both penalties. If aggravating circum-

stances are present, the penalty thus established may be increased to a maximum of ve (5) years; if extenuating circumstances are present, it

may be reduced to a minimum of two (2) years.

WARNING:

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, nes, denial of insurance and civil damages. Any insur-

ance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyhold-

er or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable

form insurance proceeds shall be reported to the Colorado Division of Insurance withing the Department of Regulatory Agencies.

Hawaii: Presenting a fraudulent claim for payment of a loss or benet is a crime punishable by nes or imprisonment, or both.

Maine/Washington: It is a crime to knowingly provide false, incomplete or misleading information ton an insurance company for the purpose of

defrauding the company. Penalties may include imprisonment, nes or a denial of insurance benets.

Minnesota: A person who les a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

New Hampshire: Any person who, with the purpose to injure, defraud or deceive any insurance company, les a statement of claim containing

any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638.20.

Tennessee and Virginia: It is a crime to knowingly provide false, incomplete or misleading information to an insurer or insurance company for

the purpose of defrauding the insurer or insurance company. Penalties include imprisonment, nes and denial of insurance benets.

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Trip Delay Claim Form To be completed by (Trip Preserver online claims)

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