Claims Department: Executive Plaza IV, 11350 McCormick Road, Suite 102, Hunt Valley, MD 21031
Phone No: 1-844-827-9994 | Fax: 1-443-279-2901 | Email: [email protected]
Arch Insurance Company
Trip Delay/Missed Connection Claim Form
AIC-19-10-TRV12
Trip Delay/Missed Connection Claim Instructions
The Trip Delay/Missed Connection Claim Form can be used to le claims for:
• Unused pre-paid portions of your trip.
• Additional Transportation costs for your outbound trip (Missed Connection Benet only).
• Additional hotel and meal accommodations following the delay of your trip or a missed travel connection.
Your claim should be submitted to the address at the top of these instructions.
For all claims, submit:
• Copy of your original travel itinerary
• Proof of all claimed expenses
• Copies of any refunds, adjustments, or credits provided by the tour operator, airlines or other travel providers;
• Documentation to support non-refundable funds, or refunds/adjustments/credits provided or denied
• For ights, please request a refund from the airline and provide us with a copy of the refund
payment or written denial;
• Proof of loss: Documentation showing the reason that your trip was delayed or your travel connection
was missed.
Name of Claimant / Insured Policy No.
To be completed by the Insured Claiming Benets
Phone No.
( )
Section 1 - Information about Insured
Email Address
Address
Briey explain the circumstances of your claim:
Traveling Companion(s
)
Name, Address & Phone No. of the other insurance company
Type of Claim
Trip Delay
Missed Travel Connection
Policy No.
Do you have other travel or other insurance that may provide coverage for this claim?
If so, has claim been submitted to the other company?
Relationship
Male
Female
Yes No
Yes No
Date of Birth
Trip Departure Date
Initial Trip Deposit Date
Trip Delay/Missed Connection Date
Trip Return Date
Travel Supplier / Tour Operator
AIC-19-10-TRV12
Claims Department: Executive Plaza IV, 11350 McCormick Road, Suite 102, Hunt Valley, MD 21031
Phone No: 1-844-827-9994 | Fax: 1-443-279-2901 | Email: claims@archinsurancesolutions.com
Arch Insurance Company
Trip Delay/Missed Connection Claim Form
Claimed Expenses
Category
Unused Hotel Expense
Unused Cruise Expense
Additional Hotel Expense
Additional Local Transportation Expense
Additional Food Expense
Other
Unused Tour Expense
Additional Airfare Expense
Total Expenses
Refunds/Credits Received
Claimed Expenses
Amount
$
$
$
$
$
$
$
$
$
$
$
Section 2 - Claimed Expenses
Enter the total of all claimed expenses in the table below. You will need to provide supporting documentation in order for the
claim to be processed. See the Trip Delay/Missed Connection Claim Instructions for required documents.
Signature of Claimant Date
Any person who knowingly and with intent to injure, defraud or deceive any insurance company, les a statement of claim
containing any false, incomplete, or misleading information may be guilty of a criminal act punishable by law
I have read the foregoing, and the above answers are true and complete according to the best of my knowledge and belief.
Please Specify:
Claims Department: Executive Plaza IV, 11350 McCormick Road, Suite 102, Hunt Valley, MD 21031
Phone No: 1-844-827-9994 | Fax: 1-443-279-2901 | Email: [email protected]
Arch Insurance Company
Trip Delay/Missed Connection Claim Form
AIC-19-10-TRV12
0.00
0.00
Authorization to Disclose Information
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 it’s authorized representative. This applies to all information about the
diagnosis, 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 Compa-
ny except to my primary health insurance carrier (if any) or persons or organizations performing investigation or legal services for the
Company in connection with my claim. A copy of this authorization shall be considered as effective and valid as the original and shall
remain in effect 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
If Authorized Representative, Relationship to Patient
or Legal Designation
Date
Alabama Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benet or who knowingly presents false information in an application for in-
surance is guilty of a crime and may be subject to restitution, nes, or connement
in prison, or any combination thereof.
Alaska A person who knowingly 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 For your protection Arizona law requires the following statement to appear on this
form. Any person who knowingly presents a false or fraudulent claim for payment of
a loss is subject to criminal and civil penalties.
Arkansas Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benet or knowingly presents false information in an application for insur-
ance is guilty of a crime and may be subject to nes and connement 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 the payment of a loss is
guilty of a crime and may be subject to nes and connement in state prison.
Colorado It is unlawful to knowingly provide false, incomplete, or misleading facts or informa-
tion 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 insurance company or agent of an insurance company who
knowingly provides false, incomplete, or misleading facts or information to a policy-
holder or claimant for the purpose of defrauding or attempting to defraud the poli-
cyholder or claimant with regard to a settlement or award payable from insurance
proceeds shall be reported to the Colorado Division of Insurance within the Depart-
ment of Regulatory Agencies.
Delaware Any person who knowingly, and with intent to injure, defraud or deceive any insurer,
les a statement of claim containing any false, incomplete or misleading information
is guilty of a felony.
District of
Columbia
WARNING: 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 impris-
onment and/or nes. In addition, an insurer may deny insurance benets if false
information materially related to a claim was provided by the applicant.
Florida Any person who knowingly and with intent to injure, defraud, or deceive any insur-
er les a statement of claim or an application containing any false, incomplete, or
misleading information is guilty of a felony of the third degree.
Idaho Any person who knowingly, and with intent to defraud or deceive any insurance
company, les a statement of claim containing any false, incomplete, or misleading
information is guilty of a felony.
State Notices
The laws of some states require us to furnish you with the following notices:
Indiana A person who knowingly and with intent to defraud an insurer les a statement of
claim containing any false, incomplete, or misleading information commits a felony.
Kentucky Any person who knowingly and with intent to defraud any insurance company or
other person les a 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.
Louisiana Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benet or knowingly presents false information in an application for insur-
ance is guilty of a crime and may be subject to nes and connement in prison.
Maine 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, nes or a denial of insurance benets.
Maryland Any person who knowingly or willfully presents a false or fraudulent claim for pay-
ment of a loss or benet or who knowingly or willfully presents false information
in an application for insurance is guilty of a crime and may be subject to nes and
connement in prison.
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 a purpose to injure, defraud, or deceive any insurance com-
pany, les a statement of claim containing any false, incomplete, or misleading in-
formation is subject to prosecution and punishment for insurance fraud, as provided
in RSA 638:20.
New Jersey Any person who knowingly les a statement of claim containing any false or mis-
leading information is subject to criminal and civil penalties.
New Mexico 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 CIVIL FINES AND CRIMINAL PENALTIES.
New York Auto claims: Any person who knowingly makes or knowingly assists, abets, solicits
or conspires with another to make a false report of the theft, destruction, damage
or conversion of any motor vehicle to a law enforcement agency, the department of
motor vehicles or an insurance company, commits a fraudulent insurance act, which
is a crime, and shall also be subject to a civil penalty not to exceed ve thousand
dollars and the value of the subject motor vehicle or stated claim for each violation.
All others: Any person who knowingly and with intent to defraud any insurance com-
pany or other person les an application for insurance or statement of claim con-
taining 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 ve
thousand dollars and the stated value of the claim for each such violation.
Ohio Any person who, with intent to defraud or knowing that he is facilitating a fraud
against an insurer, submits an application or les a claim containing a false or de-
ceptive statement is guilty of insurance fraud.
Oklahoma WARNING: Any person who knowingly, 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 Any person who knowingly and with intent to defraud or solicit another to defraud
an insurer: (1) by submitting an application, or (2) by ling a claim containing a false
statement as to any material fact thereto, may be committing a fraudulent insurance
act, which may be a crime and may subject the person to criminal and civil penal-
ties.
Pennsylvania Motor vehicles: Any person who knowingly and with intent to injure or defraud any
insurer les an application or claim containing any false, incomplete or misleading
information shall, upon conviction, be subject to imprisonment for up to seven years
and payment of a ne of up to $15,000.
All others: Any person who knowingly and with intent to defraud any insurance com-
pany or other person les an application for insurance or statement of claim con-
taining 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.
Rhode Island Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benet or knowingly presents false information in an application for insur-
ance is guilty of a crime and may be subject to nes and connement in prison.
Tennessee It is a crime to knowingly provide false, incomplete or misleading information to an
insurance company for the purpose of defrauding the company. Penalties include
imprisonment, nes and denial of insurance benets.
Texas 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 nes and connement in state prison.
Utah Workers’ Compensation Claims Only: Any person who knowingly presents false or
fraudulent underwriting information, les or causes to be led a false or fraudulent
claim for disability compensation or medical benets, or submits a false or fraudu-
lent report or billing for health care fees or other professional services is guilty of a
crime and may be subject to nes and connement in state prison.
Virginia It is a crime to knowingly provide false, incomplete or misleading information to an
insurance company for the purpose of defrauding the company. Penalties include
imprisonment, nes and denial of insurance benets.
Washington It is a crime to knowingly provide false, incomplete, or misleading information to an
insurance company for the purpose of defrauding the company. Penalties include
imprisonment, nes, and denial of insurance benets.
West Virginia Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benet or knowingly presents false information in an application for insur-
ance is guilty of a crime and may be subject to nes and connement in prison.
Puerto Rico Any person who knowingly and with the intention of defrauding presents false infor-
mation in an insurance application, or presents, helps, or causes the presentation of
a fraudulent claim for the payment of a loss or any other benet, or presents more
than one claim for the same damage or loss, shall incur a felony and, upon convic-
tion, shall be sanctioned for each violation by a ne of not less than ve thousand
dollars ($5,000) and not more than ten thousand dollars ($10,000), or a xed term
of imprisonment for three (3) years, or both penalties. Should aggravating circum-
stances be 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.
