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

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? _____________________________