Customer Property Claim Form

Please accept our sincere apologies for the inconvenience you have been caused by the delay of your checked property. To assist us with your claim, please complete and return this form. While our efforts to locate your property continue, it is of the utmost importance to promptly complete this claim form and return it to us as soon as possible. The most intensive phase of tracing is based on the information provided on this claim form. For domestic carriage, in the event you fail to return the completed claim form within 45 days, no action shall lie against United Airlines. The claim form should be completed in its entirety with a detailed description of each individual item contained within the bag(s), or the items missing from the baggage, including signatures from all persons impacted. If your claim involves more than one bag, please itemize each bag and its contents separately. The accuracy of the information you provide enhances our ability to locate your property through our tracing efforts. Failure to include requested information may affect the processing of your claim. In addition, please include the following items in addition to this signed form to assist in processing your claim: Customer copy of the flight ticket, or ticket receipt Original proof of purchase for items valued at $100 USD or higher Baggage claim checks Excess value receipt, if excess value was declared at check in For interim expense reimbursement, receipts are required for all items purchased European customers, please include bank name and address, account name and ABA/Chips number Clear copy of drivers license or other government issued photo ID for each person asserting a claim Important: Please retain copies of all documents you send to us, for your records.

Notice of Baggage Liability Limits For domestic travel between points within the United States (except for domestic portions of international journeys), Uniteds liability for loss of, damage to, or delay in delivery of a passengers checked baggage is limited to $3,400 per ticketed passenger, unless a higher value is declared in advance and appropriate charges are paid. In accordance with 14 CFR Part 382, the above limit of liability does not apply for loss, damage or delay of wheelchairs or other assistive devices. Excess value may not be declared on certain types of articles. United assumes no liability for high value, fragile, or perishable items carried in connection with domestic travel. For a complete list of excluded items, see the terms in our Contract of Carriage or at our website, united.com. For international travel to which the Montreal Convention applies, liability for loss, delay, or damage is limited to 1,131 SDR per passenger for baggage, whether checked or unchecked. Exchange rates are available at www.IMF.org. For international travel to which the Warsaw Convention applies, liability for loss, delay, or damage to baggage is limited to $20 per kilogram (approximately $9.07 per pound) up to $640, and $400 per passenger for unchecked baggage.

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For interna tionalSDR travel to which the Montreal Conven tion applies,or liability for loss, delay, or damage limited to 1,131 per passenger for baggage, whether checked unchecked. Exchange rates are is limited to 1,131 SDR per passenger for baggage, whether checked or unchecked. Exchange rates are available at www.IMF.org. available at www.IMF.org. Type of Claim: Damage Loss Pilferage Customer Property Claim Form Interim Type of Claim: Damage Interim Loss Pilferage Personal and Flight Information Personal and flight information, please type or print legibly Personal and Flight Information Please Type or Print Legibly Type of Claim: Damage Interim Loss Pilferage Please Type or Print Legibly Reference Number __________________Baggage Claim Check Numbers______________________ File File reference number Baggage Claim Check Nos. File Reference Number __________________Baggage Claim Check Numbers______________________
Name Mr. Name Mrs. Mr. Miss Mrs. Home Address Miss Home Address City City State/Province State/Province Zip/Postal Code Zip/Postal Code Total Bags Checked Total Bags Checked Did you pay checked bag service Did you paycharges? checked bag service charges? Amt: $_________ Total Bags Lost Total Bags Lost E-Mail Address E-Mail Address Country Country Number of Passengers Travelling Number of Passengers Travelling Last Last First First MI MI Home Phone Area Code Home Phone Area Code

( ) ( )on Occupati
Occupation

( ) ( ) By Employed
Employed By

Business Phone Areas Code Business Phone Areas Code

Business Street Address Business Street Address City/State/Province City/State/Province Zip/Postal Code Zip/Postal Code MileagePlus or Frequent Flyer Number/Airline MileagePlus or Frequent Flyer Number/Airline Country Country When and where Was your last seen? When andbag where Was your bag last seen?

Did you declare and Yes Yes Did declare and pay you for higher value? Yes Yes No Value: $_________ pay for higher value? No Amt: $_________ No Value: Was your bag(s) Yes If yes, were you $_________ Yes No rerouted given dierent Yes If yes, a were you Yes Was youror bag(s) rerouted or given a dierent rechecked enroute? No claim check? No rechecked No claim No Atcheck? what UA oce did you report Did you attenroute? empt to Yes your loss? At what UA oce did you report claim baggage asto Yes Did you attempt your loss? claim baggage as soon as you arrived? No soon as you arrived? No Have you or members of your household ever led a claim before Have you or members of your ever led a claim before this one with any airline(s) for household baggage loss, damage, or pilferage? this one with any airline(s) for baggage loss, damage, or pilferage?

rerou ting City and Airline who handled rerouting

Where did you check your baggage? Where did you check your baggage? Ticket Counter________ Curbside_______ Other_________ Ticket Counter________ Curbside_______ City and Airline who handled Reason for Reroute Other_________ Reason for Reroute

Complete itinerary

From From

To To

Complete Itinerary Complete Itinerary Airline Airline

Yes No airline and city where reported: If yes, please give If yes, please give airline and city where reported: Yes If yes, Airline(s)__________________________________ Yes If yes, Airline(s)__________________________________ No Date(s)__________________________________ No Date(s)__________________________________

Has loss been reported to another airline? Has Yes loss been reported No to another airline?

Flight # Flight #

Date Date

Certication and Understanding Certication and Understanding The United States Post Oce has investigative jurisdiction under federal laws relating to sending false or Certification and understanding The Unitedclaims States through Post Othe ce has inves tigative jurisdic tisuch on under federal laws rela ting to sending false or fraudulent United States mails. Any claims received by United Airlines are The fraudulent United States Post Office has investigative jurisdiction under federal laws relating to sending false claims through the States mails. Any such claims received by United Airlines are reported to US Postal authori tiUnited es. or fraudulent claims through the United States mail. Any such claims received by United Airlines are reported to US Postal authorities.
reported to US Postal authorities. I do hereby promise the foregoing statement and those on all accompanying forms and supporting documents to be accurate, complete, true and I hereby make a claim against United Airlines in the amount of $ for loss occurring on , 20 .
Requires signature of each customer claiming lost property.
Customer Signature Date Customer Signature Date

Customer Signature

Date

Customer Signature

Date

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Customer Signature*
*Requires signature Claim of each customer Customer Property Form claiming lost property. Baggage Description and Contents Listing Baggage description and contents listing
List contents separately if more than one bag Type of Bag Color of Bag Manufacturer

Date

, 20

Date Purchased

Original Cost

Initials, Marks, Labels, or other Exterior Identification. List name of any person(s) which may be on documents, papers, etc. Description of contents: If claim is for more than 1 customer, please indicate ownership of items. Gender: M= Male, F= Female, CH=Child, INF= infant (0-3 yrs.)

Qty

Article/Item

Size

Gender
M, F, CH, INF

Description, Color, Material, Brand Label

Where Purchased

Date Purchased

Original Cost

Shirt

XL

Red button up, cotton, Polo

Dillard

May, 2010 $65.00

If additional space is needed, please attach separate paper with same data as above

Total value of bag and contents

Reminders
Include the following items with your claim Include the following items with your claim

ticket Passenger ticket receipts each person involved in loss this loss Passenger receipts for each for person involved in this Baggage claim checks Baggage claim checks Excess value receipt, if applicable Excess value receipt, if applicable Interim Expense Reimbursement receipts Interim Expense Reimbursement receipts
Copy of drivers license or other government issued photo ID for each person in the claim Include original proof of purchase for items valued at $100 or higher Mail or fax to: United Airlines, Inc. Baggage Resolution Service Center 611 Lockhaven Drive Houston, TX 77073 Phone 1-800-335-2247 Local 1-281-821-3526 Fax 1-281-553-1484

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