how to request excess medical benefits - Chubb Group of Insurance ...

CHUBBPrimaryBaggage ProtectionBaggage DelayHOW TO FILE A CLAIM1. Complete all items on the attached claim form.2. Attach the following documents:• Copy of payment or denial from common carrier (e.g., airline, railroad,cruise ship, bus, etc.)• Copy of all receipts or estimates for all property lost or damaged• Copy of receipts for all expenses incurred as a result of loss (Baggage Delayonly)3. Send the completed and signed claim form and all required documents to:CHUBB GROUP OF INSURANCE COMPANIESCLAIM SERVICE CENTER600 INDEPENDENCE PARKWAYP.O. BOX 4700CHESAPEAKE, VA 23327-47004. Retain a copy of all material for your records.YOU WILL BE CONTACTED BY A CLAIM ADJUSTER IF ADDITIONALINFORMATION OR DOCUMENTATION IS REQUIRED.IF YOU HAVE ANY CLAIM RELATED QUESTIONS PLEASECALL CHUBB AT 1-800-CLAIMS-0 (1-800-252-4670)

CHUBBPrimaryBaggage ProtectionBaggage DelayInsured’s Statement(Please print – Attach separate sheet if additional space required)INSURED INFORMATIONInsured’s Name________________________________________________________________ Soc. Sec. No. _______-_______-_______Insured’s Address______________________________________________________________ Phone No. (H)_______________________________________________________________________________________________________ Phone No. (W)_________________________Policy Number (Required)________________________CLAIM INFORMATIONDate of loss, damage or delay ______/_______/_______ Time of day _____________ a.m. p.m.Please describe in detail where and how the loss, damage or delay occurred: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Please describe in detail the nature and extent of loss, damage or delay: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Did loss, damage or delay occur while insured property was on, or in the custody of a common carrier (e.g., railroad, airline, cruise ship,bus, taxi, etc.)? If yes, please complete the following:Name of carrier: ______________________________________Flight, trip or tour number: ______________________________Was the carrier notified at the time of the loss or damage? ____ If yes, please identify where, when and to whom (name and title) notificationwas given:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Was extra valuation on property declared? __________Was baggage checked at the time of loss or damage? _________If yes, how much? _________________________________If yes, please enclose claim checkHas formal claim been filed against the carrier? __________If yes, has payment been made to you? ________________If yes, amount received? _____________________________

CLAIM INFORMATION (Cont’d)Was loss reported to police or other authorities? _________ If yes, please identify where, when and to whom (name and title) loss wasreported: __________________________________________________________________________ Case # ____________________________Valuation of lost and / or damaged propertyDescription Date and place of purchase Original CostReplacementCost or EstimateAmountClaimed123456789(attach bills of sale, receipts or estimates)Are any claimed items used in your business, occupation or profession? ______________If yes, identify the item(s) by * above.AUTHORIZATIONI authorize any insurance company, any travel organization or agency, airline carrier, cruise line, tour operator, rental agency, hotel, motelor similar entity providing lodging on a rental/lease basis or any other person who may have knowledge regarding this claim to release anyinformation requested regarding this claim and the loss reported.I understand this information will be used by the Chubb Group of Insurance Companies, or its authorized representatives, for the purpose ofevaluating and determining coverage for this claim. I know I have a right to receive a copy of this authorization upon request and agree thata photographic or facsimile copy of this authorization is as valid as the original. I agree that this authorization shall be valid for the durationof this claim.I understand that any person who knowingly and with intent to defraud or deceive any insurance company files a claim containing anymaterially false, incomplete or misleading information may be subject to prosecution for insurance fraud.Signed (Insured or authorized person) _________________________________________________________________ Date ____/____/____

IMPORTANT NOTICENotice to Alaska Claimants: A person whoknowingly and with intent to injure, defraud, ordeceive an insurance company files a claimcontaining false, incomplete, or misleadinginformation may be prosecuted under state law.Notice to Arizona Claimants: For your protection,Arizona law requires the following statement toappear on this form: Any person who knowinglypresents a false or fraudulent claim for payment of aloss is subject to criminal and civil penalties.Notice to Arkansas Claimants: Any person whoknowingly presents a false or fraudulent claim forpayment of a loss or benefit or knowingly presentsfalse information in an application for insurance isguilty of a crime and may be subject to fines andconfinement in prison.Notice to California Claimants: For yourprotection, California law requires the following toappear on this form: Any person who knowinglypresents a false or fraudulent claim for the paymentof a loss is guilty of a crime and may be subject tofines and confinement in state prison.Notice to Colorado Claimants: It is unlawful toknowingly provide false, incomplete, or misleadingfacts or information to an insurance company for thepurpose of defrauding or attempting to defraud thecompany. Penalties many include imprisonment,fines, denial of insurance, and civil damages. Anyinsurance company or agent of an insurancecompany who knowingly provides false, incomplete,or misleading facts or information to a policyholderor claimant for the purpose of defrauding orattempting to defraud the policyholder or claimantwith regard to a settlement or award payable frominsurance proceeds shall be reported to the ColoradoDivision of Insurance within the Department ofRegulatory Agencies.Notice to Delaware Claimants: Any person whoknowingly, and with intent to injure, defraud ordeceive any insurer, files a statement or claimcontaining any false, incomplete, or misleadinginformation is guilty of a felony.Notice to District of Columbia Claimants:WARNING: It is a crime to provide false ormisleading information to an insurer for the purposeof defrauding the insurer or any other person.Penalties include imprisonment and/or fines. Inaddition, an insurer may deny insurance benefits iffalse information materially related to a claim wasprovided by the applicant.Notice to Florida Claimants: Any person whoknowingly and with intent to injure, defraud ordeceive any insurer files a statement of claim or anapplication containing any false, incomplete, ormisleading information, is guilty of a felony of thethird degree.Notice to Idaho Claimants: Any person whoknowingly, and with intent to defraud or deceive anyinsurance company, files a statement containing anyfalse, incomplete, or misleading information, isguilty of a felony.Notice to Indiana Claimants: A person whoknowingly and with intent to defraud an insurer filesa statement of claim containing any false,incomplete, or misleading information commits afelony.Notice to Kentucky Claimants: Any person whoknowingly and with intent to defraud any insurancecompany or other person files a statement of claimcontaining any materially false information orconceals, for the purpose of misleading, informationconcerning any fact material thereto commits afraudulent insurance act, which is a crime.Notice to Maine Claimants: It is a crime toknowingly provide false, incomplete or misleadinginformation to an insurance company for thepurpose of defrauding the company. Penalties mayinclude imprisonment, fines or a denial of insurancebenefits.Notice to Maryland Claimants: Any person whoknowingly or willfully presents a false or fraudulentclaim for payment of a loss or benefit or whoknowingly or willfully presents false information inan application for insurance is guilty of a crime andmay be subject to fines and confinement in prison.

IMPORTANT NOTICENotice to Minnesota Claimants: A person whosubmits an application or files a claim with intent todefraud or helps commits a fraud against an insureris guilty of a crime.Notice to New Hampshire Claimants: Any personwho, with a purpose to injure, defraud or deceiveany insurance company, files a statement of claimcontaining any false, incomplete or misleadinginformation is subject to prosecution andpunishment for insurance fraud, as provided in RSA638:20.Notice to New Jersey Claimants: Any person whoknowingly files a statement of claim containing anyfalse or misleading information is subject tocriminal and civil penalties.Notice to New Mexico Claimants: Any personwho knowingly presents a false or fraudulent claimfor payment of a loss or benefit or knowinglypresents false information in an application forinsurance is guilty of a crime and may be subject tocivil fines and criminal penalties.Notice to New York Claimants: Any person whoknowingly and with intent to defraud any insurancecompany or other person files an application forinsurance or statement of claim containing anymaterially false information, or conceals for thepurpose of misleading, information concerning anyfact material thereto, commits a fraudulent insuranceact, which is a crime and shall also be subject to acivil penalty not to exceed five thousand dollars andthe stated value of the claim for each such violation.Notice to Oregon Claimants: Any person who,knowingly and with intent to defraud an insurancecompany or other person, submits an application orfiles a claim for insurance that contains anymaterially false information relating to an insurancecompany’s acceptance of risk, or conceals for thepurpose of misleading, information concerning anyfact material to an insurance company’s acceptanceof risk, may be guilty of a fraudulent act, which is acrime.Notice to Pennsylvania Claimants: Any personwho knowingly and with intent to defraud anyinsurance company or other person files anapplication for insurance or statement of claimcontaining any materially false information orconceals for the purpose of misleading, informationconcerning any fact material thereto commits afraudulent insurance act, which is a crime andsubjects such person to criminal and civil penalties.Notice to Virginia Claimants: It is a crime toknowingly provide false, incomplete or misleadinginformation to an insurance company for thepurpose of defrauding the company. Penaltiesinclude imprisonment, fines and denial of insurancebenefits.Notice to Claimants in all other states: Anyperson who knowingly and with intent to defraud ordeceive any insurance company files a claimcontaining any materially false, incomplete ormisleading information may be subject toprosecution for insurance fraud.Notice to Ohio Claimants: Any person who, withthe intent to defraud or knowing that he isfacilitating a fraud against an insurer, submits anapplication or files a claim containing a false ordeceptive statement is guilty of insurance fraud.Notice to Oklahoma Claimants: WARNING: Anyperson who knowingly, and with intent to injure,defraud or deceive any insurer, makes any claim forthe proceeds of an insurance policy containing anyfalse, incomplete or misleading information is guiltyof a felony.