Fillable Trip Delay Claim Form To be completed by (Trip Preserver online claims)

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Trip Delay Claim Form To be completed by (Trip Preserver online claims)

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The Trip Delay Claim Form To be completed by (Trip Preserver online claims) form is 2 pages long and contains:

  • 1 signature
  • 5 check-boxes
  • 50 other fields

Country of origin: US
File type: PDF

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Trip Delay
Claim Form
To be completed by the Insured / Guest
Name of Insured / Guest Reservation #
Address Work Phone # Home Phone #
E-mail Address Date of Birth
Scheduled Departure Date Scheduled Return Date Date Delayed (mm/dd/yy)
Name and Address of Property Management Company Phone # Fax #
Name of leaseholder on the rental property and list all guests occupying the property
Please Briey explain your claim:
Is there any other insurance that provides coverage for this loss (homeowners, renters, credit card, other travel insurance)?
If yes, please provide name of insurance company, policy number, and address
Please check the box which applies to your claim
Additional accommodation and meal expenses
Amount being claimed: ___________________
Additional Transportation Expenses
Amount being claimed: ___________________
Prepaid, Unused non-refundable land and water accommodation trip costs
Amount being claimed: ___________________
Please supply the following items based on which box you’ve checked.
3
If delay is due to a common carrier delay, please provide us with written verication from the common carrier as to the cause and
length of your delay. Please include your ight itinerary or ticket copies from your common carrier. If not, provide documentation
verifying the case of delay.
• For additional Accommodation Expenses:
￮ Please provide us with proof of payment for additional accommodations and meal expenses (invoices or receipts and a copy
of your canceled check or credit card statement showing payment for the additional expenses).
• For additional Transportation Expenses:
￮ Please provide us with proof of payment for additional transportation expenses (invoices or receipts and a copy of cancelled
checks or credit card statement showing payment for the additional expenses).
• For pre-paid, unused non-refundable land and water trip costs:
￮ Please provide us with proof of payment for pre-paid, unused non-refundable land and water trip costs (invoices or receipts
and a copy of cancelled checks or credit card statement showing payment for the additional expenses).
3 If claimant is other than leaseholder, please provide a signed written statement from leaseholder listing all guests occupying the
rental property.
Arch-2014
Yes No
Claims Department:
Red Sky Claims, C/O Arch Insurance Company
Executive Plaza IV, 11350 McCormick Road, Suite 102, Hunt Valley, MD 21031 United States
Toll Free Phone: (844) 800-2486 | Fax: (443) 279-2901 | E-mail: redsky@archinsurance.com
Any person who knowingly presents a false or fraudulent claim for payment of loss or benet or
knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to nes and connement in prison.
Trip Delay
Claim Form
List all guests occupying the rental property
Guest Name: Claiming trip delay?
Yes No
Guest Name: Claiming trip delay?
Yes No
Guest Name: Claiming trip delay?
Yes No
Guest Name: Claiming trip delay?
Yes No
Guest Name: Claiming trip delay?
Yes No
Guest Name: Claiming trip delay?
Yes No
Guest Name: Claiming trip delay?
Yes No
Guest Name: Claiming trip delay?
Yes No
Guest Name: Claiming trip delay?
Yes No
______________________ Total expenses being claimed
Authorization to Disclose Information
Trip Preserver Product is Underwritten by Arch Insurance Company.
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 its authorized representative. This applies to all information about the diag-
nosis, 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 Company
except to my primary health insurance carrier (if any) or persons or organizations performing investigation or legal services for the Compa-
ny in connection with my claim. A copy of this authorization shall be considered as eect and valid as the original and shall remain in eect
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 Date
If Authorized Representative, Relationship to Patient
or Legal Designation
Arch-2014
Claims Department:
Red Sky Claims, C/O Arch Insurance Company
Executive Plaza IV, 11350 McCormick Road, Suite 102, Hunt Valley, MD 21031 United States
Toll Free Phone: (844) 800-2486 | Fax: (443) 279-2901 | E-mail: redsky@archinsurance.com
Any person who knowingly presents a false or fraudulent claim for payment of loss or benet or
knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to nes and connement in prison.
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Trip Delay Claim Form To be completed by (Trip Preserver online claims)

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Completed 12 September 2021

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