ࡱ> ac`w .,bjbjnn 7Zff#c RR8L:l.8k%k%k%w-y-y-y-y-y-y-$L03-'I%"k%''-RR-&W,W,W,'RR8w-W,'w-W,W,W,@C(RW,c--<.W,3(3W,W,3k,k%'&W,&l'k%k%k%--[*k%k%k%.''''3k%k%k%k%k%k%k%k%k% X :  Baggage & Personal Effects Claim Form & Claimants Statement Insurance Carrier: Lloyds of London Program Reference # EQX2020003 Group Name: UHP Schools - Cigna Wrap Plan School Name:_______________________________ PLAN PARTICIPANTS INFORMATION: Date of Birth:_______/_______/_______ Name: ________________________________________ Home Phone #: (________) _____________________ Email Address: _________________________________ Address: ________________________________________ City:______________________ State:____ Zip Code:________ LOSS INFORMATION: Date of Loss: _____ /______ /______ Please describe what occurred: ________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Place of Loss: (common carrier land, air or sea) Company Name and Address: _____________________________________________________________________________ Phone #: (________)_______________________ Contact: _____________________________________ DOCUMENTATION REQUIREMENTS: Depending upon the circumstance involved in the loss, one or more of the following items may be required to complete the processing of your claim. Please place a check by those items you have attached. We recommend you keep copies of any items submitted with this claim. ____ Airline Ticket Stub/Receipt ____ Police Report ____ Statement from Airline Carrier or Airport Facility or other common carrier that concerns your lost property. Note: You must file a report with the appropriate authorities for damaged, lost or stolen property. ____ Copies of reimbursement statements issued by an airline carrier, airport facility or other common carrier or any other insurance company providing reimbursement to you for the loss. ____ Proof of ownership of the items lost or stolen Note: Acceptable forms of proof of purchase include credit card statements, sales receipts or cancelled checks. ____ Other (please describe):__________________________________________________________________ DESCRIPTION OF LOST / STOLEN / DAMAGED ITEMS: Item(s):Estimated Value:Have you received reimbursement?If so, from whom?How much?$Yes No $$Yes No$$Yes No $$Yes No $Total$$ OTHER INSURANCE / AUTHORIZATION: Company Name and Address:____________________________________________________________________________ Type of Policy: __________________________________ Policy #: _______________________________________ I AUTHORIZE any insurance company, 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 regarding this claim and the loss reported. I UNDERSTAND the information obtained by use of the authorization, will be used by the Claims Administrator to determine eligibility for benefits under this plan. Any information obtained will not be released by the Claims Administrator to any person or organization EXCEPT to reinsuring companies, or other persons or organizations performing business or legal services in connection with my claim, or as may be otherwise lawfully required or as I further authorize. I KNOW that I may request to receive a copy of the Authorization. I AGREE that a photographic copy of this authorization is as valid as the original. I AGREE that this Authorization shall be valid for two and one half years from the date shown below. I UNDERSTAND that it is illegal to knowingly file a false or fraudulent claim or to knowingly help someone else file one. I have read and understand the Fraud Notices on page 3 of this document. _________________________________________ ___________________________ Signed Date CLAIM INSTRUCTIONS: Send this form and any accompanying documentation to: Attention: Co-ordinated Benefit Plans, LLC On Behalf of Underwriters at Lloyds, London P.O. Box 26222, Tampa, FL 33623 Or, E-mail your information to:  HYPERLINK "mailto:TravelTeam@cbpinsure.com" TravelTeam@cbpinsure.com Phone: 888-617-1301 / Fax: 800-560-6340 FRAUD STATEMENTS If you reside in the state of: 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. District of Columbia: 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. Maryland: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. 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. California: For your protection California law requires the following to appear on this form. 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. Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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. Louisiana: 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. Missouri: An insurance company or its agent or representative may not ask an applicant or policyholder to divulge in a written application or otherwise whether an insurer has canceled or refused to renew or issue to the applicant or policyholder a policy of insurance. If a question(s) appears in this application, you should not renew it. 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. Puerto Rico: Any person who, knowingly and with the intent to defraud, presents false information in an insurance request form, or who presents, helps or has presented a fraudulent claim for the payment of a loss or other benefit, or presents more than one claim for the same damage or loss, will incur a felony, and upon conviction will be penalized for each violation with a fine of no less than five thousand (5,000) dollars nor more than ten thousand (10,000) dollars, or imprisonment for a fixed term of three (3) years, or both penalties. If aggregated circumstances prevail, the fixed established imprisonment may be increased to a maximum of five (5) years; if attenuating circumstances prevail, it may be reduced to a maximum of two (2) years. Washington: Any person who knowingly presents a false or fraudulent claim for payment of a loss or knowingly makes a false statement in an application for insurance may be guilty of a criminal offense under state law. All Other States: 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/or civil penalties.     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