Page 1 of 4© 2019 American International Group, Inc. All rights reserved.
Full name
Position
Telephone number
Email address
Is this claim payable direct to the company?
Travel destination
Scheduled trip dates
Travel order number (if applicable)
Reason for travel Business trip Leisure Long term secondment
Country where accident occurred
Policy number
Name of company
Address
Postcode
Does the claimant work at this address?
If not where does the claimant work? Please name branch/subsidiary and location
YES
YES
NO
NO
The claimant should complete and sign this form. If the claimant is under 18 years of age, this form should be completed by one of their
parents or legal guardians. If the claimant is unable to complete this form, the person completing and signing this form should give their
details in the Declaration on page 4.
Please note: You may be able to process your claim for the loss, damage or delay of your personal property without filling in this form. Call
Concierge Claims Service at 0844 892 0319 (UK only) or +44 (0) 20 7359 3433 (overseas). This service is designed to conclude over
90% of baggage and money claims within 15 minutes on the phone. You can also email us: [email protected].
Personal Property and Money Claim Form — Loss, Damage or Delay (Temporary Loss)
Lifeline Plus Group Personal Accident and Travel Insurance
If you claim as a company representative (HR, Finance, etc.) please provide your details:
Full name
Address
Postcode
Telephone number
Email address
Occupation
Relationship to policyholder Employee Spouse of employee Visitor
Contractor Child of employee Other (please state)
If the deceased person is a spouse or child of an employee,
please provide the name of the employee
Country
Date of birth
Details of the claimant (person who suffered the personal property loss, damage or delay):
DD / MM / YYYY
DD / MM / YYYY DD / MM / YYYY
Country
Details of the policyholder (insured company):
to
Details of the trip:
Page 2 of 4© 2019 American International Group, Inc. All rights reserved.
Do you have Home Contents/All Risk Insurance?
If Yes, company name
Policy number
Company address
Have you made any previous claims on this type of insurance?
If Yes, give full details
Approximate total value of the insured property at the time of loss
Were police/carrier advised?
Police station, if known
Carrier name, if known
Have you received any settlement from the carrier directly?
If Yes, state amount
YES
YES
YES
YES
NO
NO
NO
NO
Details of the lost,
damaged or delayed
items
Where and when did
the loss, damage or
delay occur?
Who discovered it?
When was it discovered?
Cause of loss, damage
or delay (e.g. fire, theft)
If delayed, how long was the property delayed?
DD / MM / YYYY
Details of loss, damage or delay (temporary loss):
Circumstances of loss, damage or delay (temporary loss):
Insurance details:
List of damaged or lost items (or list of emergency purchases if property was delayed or temporarily lost):
Property description Owner’s name
Seller/donor’s
name
Seller/donor’s
address
Date
acquired
Price
paid
Replacement
cost
Amount
claimed
DD / MM / YYYY
DD / MM / YYYY
DD / MM / YYYY
DD / MM / YYYY
DD / MM / YYYY
TotalNote: Invoices or receipts should be made available.
Page 3 of 4© 2019 American International Group, Inc. All rights reserved.
If bank transfer:
Name of account holder Account number
Name of bank
Address of bank
Sort code (UK only)
For international transfers only (outside UK):
International bank account number (IBAN)
SWIFT/IBC Code Account currency
Do you require a bank transfer? Do you require a cheque?
If cheque, make payment to
YES YESNO NO
How we use personal information:
American International Group UK Limited is committed to protecting the privacy of customers, claimants and other business contacts.
“Personal Information” identifies and relates to you or other individuals (e.g. your partner or other members of your family). If you provide
Personal Information about another individual, you must (unless we agree otherwise) inform the individual about the content of this notice
and our Privacy Policy and obtain their permission (where possible) for sharing of their Personal Information with us.
American International Group UK Limited is committed to protecting the privacy of customers, claimants and other business contacts.
“Personal Information” identifies and relates to you or other individuals (e.g. your partner or other members of your family). If you provide
Personal Information about another individual, you must (unless we agree otherwise) inform the individual about the content of this notice
and our Privacy Policy and obtain their permission (where possible) for sharing of their Personal Information with us.
The types of Personal Information we may collect and why – Depending on our relationship with you, Personal Information collected may
include: contact information, financial information and account details, credit reference and scoring information, sensitive information about
health or medical conditions (collected with your consent where required by applicable law) as well as other Personal Information provided
by you or that we obtain in connection with our relationship with you. Personal Information may be used for the following purposes:
n Insurance administration, e.g. communications, claims processing and payment
n Make assessments and decisions about the provision and terms of insurance and settlement of claims
n Assistance and advice on medical and travel matters
n Management of our business operations and IT infrastructure
n Prevention, detection and investigation of crime, e.g. fraud and money laundering
n Establishment and defence of legal rights
n Legal and regulatory compliance (including compliance with laws and regulations outside your country of residence)
n Monitoring and recording of telephone calls for quality, training and security purposes
n Marketing, market research and analysis
Sharing of Personal Information — For the above purposes Personal Information may be shared with our group companies and third
parties (such as brokers and other insurance distribution parties, insurers and re-insurers, credit reference agencies, healthcare professionals
and other service providers). Personal Information will be shared with other third parties (including government authorities) if required by
laws or regulations. Personal Information (including details of injuries) may be recorded on claims registers shared with other insurers. We
are required to register all third party claims for compensation relating to bodily injury to workers’ compensation boards. We may search
these registers to prevent, detect and investigate fraud or to validate your claims history or that of any other person or property likely to be
involved in the policy or claim. Personal Information may be shared with prospective purchasers and purchasers, and transferred upon a
sale of our company or transfer of business assets.
International transfer — Due to the global nature of our business, Personal Information may be transferred to parties located in other
countries (including the United States, China, Mexico Malaysia, Philippines, Bermuda and other countries which may have a data
protection regime which is different to that in your country of residence). When making these transfers, we will take steps to ensure that
your Personal Information is adequately protected and transferred in accordance with the requirements of data protection law. Further
information about international transfers is set out in our Privacy Policy (see below).
Security of Personal Information — Appropriate technical and physical security measures are used to keep your Personal Information
safe and secure. When we provide Personal Information to a third party (including our service providers) or engage a third party to collect
Personal Information on our behalf, the third party will be selected carefully and required to use appropriate security measures.
Please complete if a payment may be due:
Page 4 of 4© 2019 American International Group, Inc. All rights reserved.
Declaration:
We declare that the information provided is correct to the best of my knowledge and belief. I understand that a false declaration may
invalidate my claim and could result in prosecution. I give permission for my personal information to be used and shared in the ways
described above. I confirm that I will not provide any personal information about another person without that person’s permission.
Signature
Date
DD / MM / YYYY
Full name
Telephone number
Email address
Relationship to claimant
Reason for completing the
form on behalf of the claimant
Details of the person completing the form (if not the claimant):
Your rights — You have a number of rights under data protection law in connection with our use of Personal Information. These rights may
only apply in certain circumstances and are subject to certain exemptions. These rights may include a right to access Personal Information,
a right to correct inaccurate data, a right to erase data or suspend our use of data. These rights may also include a right to transfer your
data to another organisation, a right to object to our use of your Personal Information, a right to request that certain automated decisions
we make have human involvement, a right to withdraw consent and a right to complain to the data protection regulator. Further information
about your rights and how you may exercise them is set out in full in our Privacy Policy (see below).
Privacy Policy — More details about your rights and how we collect, use and disclose your Personal Information can be found in
our full Privacy Policy at https://www.aig.co.uk/privacy-policy or you may request a copy by writing to: Data Protection Officer,
American International Group UK Limited, The AIG Building, 58 Fenchurch Street, London EC3M 4AB.or by email at:
dataprotectionofficer[email protected].
Please include the following documents:
n The carrier’s property irregularity report (PIR) or letter confirming loss, damage or delay
n Police reports if applicable
n Receipts, valuation forms and photos as appropriate
THE ISSUE OF THIS FORM DOES NOT CONSTITUTE AN ADMISSION OF LIABILITY UNDER THE POLICY.
To help us process your claim quickly, please make sure all sections are completed in full and all requested documents are scanned and
emailed or posted to us.
A&H Claims, American International Group UK Limited, The AIG Building,
2-8 Altyre Road, Croydon, Surrey CR9 2LG, United Kingdom
Telephone: +44 345 602 9429
Fax: +44 20 8253 7569
SUBMIT
FORM
AT-10914-18 R05/19
Products and services are written or provided by subsidiaries or affiliates of American International Group, Inc. In the UK, the principal insurance provider is American
International Group UK Limited. This material is for information purposes. Not all products and services are available in every jurisdiction, and insurance coverage is governed
by the actual terms and conditions of insurance set out in the policy or in the insurance contract. Certain products and services may be provided by independent third parties.
Insurance products may be distributed through affiliated or unaffiliated entities. For additional information, please visit our website at www.aig.com.
American International Group UK Limited is registered in England: company number 10737370. Registered address: The AIG Building, 58 Fenchurch Street, London EC3M
4AB. American International Group UK Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and Prudential Regulation
Authority (FRN number 781109). This information can be checked by visiting the FS Register (www.fca.org.uk/register).
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