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. 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 light 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 and legible copy of driver’s license or other government issued photo ID for each person on 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 interna-
tional journeys), United’s liability for loss of, damage to, or delay in delivery of a passenger’s checked
baggage is limited to $3,300 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 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.

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.

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 For international
limited travel
to 1,131 SDR pertopassenger
which thefor
Montreal
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whether checked liability for loss,
unchecked. delay, orrates
Exchange damage
are is
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available at www.IMF.org. passenger for baggage, whether checked or unchecked. Exchange rates are
available at www.IMF.org.
Customer Property
Type of Claim: DamageClaim Form Interim Loss Pilferage
Type of Claim: Damage Interim Loss Pilferage
Personal and Flight Information
Personal and light information, please type orand
Personal print legibly
Flight Information
Type of Claim: Damage Please
Interim Type or
Loss Print Legibly
Pilferage
Please Type or Print Legibly
File File Reference
reference Number
number __________________Baggage
ZRHUA25611 ClaimClaim
Baggage CheckCheck
Numbers______________________
Nos. CM086547
File Reference Number __________________Baggage Claim Check Numbers______________________
Name Last First MI Home Phone Business Phone N/A
Mr.
Name Last First MI Area Code
Home Phone Areas Code
Business Phone
Mrs.
Mr.
Miss
Mrs.
CEDENO CRUZ KAREN LUBYANKA ( 507 ) 3996594
Area Code
( 507 ) 62424537
Areas Code

Home Address
Miss
( )
Occupation (Employed) By
Home Address Occupation Employed By
PH Quintas del Lago 107 Las Cumbres Mechanical Engineer Independent Professional
City Business Street Address
City Business Street Address
Panama
State/Province E-Mail Address City/State/Province
State/Province
Panama E-Mail Address
karencedenocruz@gmail.com City/State/Province
Zip/Postal Code Country Zip/Postal Code Country
Zip/Postal Code
na Country
Panama Zip/Postal Code Country
Total Bags Checked Total Bags Lost Number of Passengers MileagePlus or Frequent Flyer When and where
Total Bags Checked Total Bags Lost Travellingof Passengers
Number Number/Airline
MileagePlus or Frequent Flyer Was your
When andbag last seen?
where
Travelling Number/Airline Was your bag last seen?
1 1 1 232257515/Copa 02/26, USA
Excess Bag Yes Did you declare and Yes Where did you check your baggage?
Fee Paid?
Excess Bag Yes Did
pay you and Yes Value: $__________
declarevalue?
for higher Where did you check your baggage?
Fee Paid? No pay for higher value? No Value: $__________ Ticket Counter________
1 Curbside_______ Other_________
No Ticket Counter________ Curbside_______ Other_________
Was your bag(s) Yes If yes, wereNo you Yes City and Airline who handled Reason for Reroute
rerouted
Was youror bag(s) Yes given
If yes, awere
different
you Yes rerouting
City and Airline who handled Reason for Reroute
rerouted
recheckedorenroute? No given check?
claim a different No rerouting
FRA/LH Wrong Country
rechecked enroute?
Did you attempt to No
Yes claim what UA office did youNo
Atcheck? report Has loss been reported to another airline?
claim baggage
Did you attemptasto Yes your
At loss?
what UA office did you report Yes No to another airline?
Has loss been reported
claim baggage
soon as as
you arrived? No your loss?
Zurich Yes No airline and city where reported:
If yes, please give
soon as you arrived? No
Have you or members of your household ever filed a claim before YesIf yes, please give
If yes, airline and city where reported:
Airline(s)__________________________________
Haveone
this youwith
or members of your
any airline(s) for household ever
baggage loss, filed a claim
damage, before
or pilferage? Yes
No If yes, Airline(s)__________________________________
Date(s)__________________________________
this one with any airline(s) for baggage loss, damage, or pilferage? No Date(s)__________________________________
Complete Itinerary
Complete itinerary Complete Itinerary
From To Airline Flight # Date
From To Airline Flight # Date
PTY IAD Copa 304 02/26/2020
IAD ZRH United 52 02/26/2020

Certification and Understanding

Certification and Understanding
The United
Certiication andStates Post Office has investigative jurisdiction under federal laws relating to sending false or
understanding
The Unitedclaims
fraudulent States through
Post Office
thehas investigative
United jurisdiction
States mails. Any suchunder federal
claims lawsbyrelating
received Unitedto sending
Airlines arefalse or
The fraudulent
United States Post
claims Ofice
through has investigative jurisdiction under federal laws relating to
the United States mails. Any such claims received by United Airlines are sending false
reported toclaims
or fraudulent US Postal authorities.
through the United States mails. 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 $ 625.43 for loss occurring on 02/27 , 20 20 .

Requires signature of each customer claiming lost property.

Customer Signature Verified by PDFfiller Date Customer Signature Date
02/29/2020

02/29/2020
Customer Signature Date Customer Signature Date

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 Customer Signature* Date , 20 .

Customer Property
*Requires signature Claim Form claiming lost property.
of each customer

Baggage Description and Contents Listing

Baggage description and contents listing

List contents separately if more than one Type of Bag Color of Bag Manufacturer Date Purchased Original Cost
bag upright design black Samsonite 2018 90.00
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 Description, Color, Material, Brand Label Where Date Original
M, F, CH, INF Purchased Purchased Cost
1 Shirt XL M Red button up, cotton, Polo Dillard May, 2010 $65.00
Blouse XL F blouse, gold, polyester, Zara Zara Feb, 2020 35.00
Shirt XL F shirt, light blue, cotton, Zara Zara Feb, 2020 35.00
Blazer XL F blazer, black, polyester, Zara Zara Feb, 2020 80.00
Trouser XL F formal trouser, black, wool, Worth Dorians Feb, 2020 40.00
Trouser XL F formal trouser, gray, cotton, Ralph Lauren Dorians Feb, 2020 40.00
Winter Jacket XL F winter jacket, olive, polyester, H&M Dorians March, 2019 90.00
Sweater XL F winter sweater, pink, polyester, Calvin Klein Dorians Feb, 2020 30.00
Sweater XL F winter sweater, black, wool, H&M, Dorians Feb, 2020 30.00
Coat XL F top coat, blue, cotton, Anne Klein Dorians Feb, 2020 50.00
Underwear 34B F Bras(3), panties, leggings, tights,Calvin Klein Nordstrom March, 2019 90.00
Perfume 100 F perfume, gold, Gucci Nordstrom March, 2019 70.00
Shoes 7 F closed formal shoes, black, leather, Clarks Clarks June, 2019 70.00
Makeup F Makeup, Foundation, liquid liner, etc, Revlon Pharmacy Feb, 2020 65.00
Accesories F Bag, jewerly, winter accesories, Stevens June, 2019 90.00
If additional space is needed, please attach separate paper with same data as above Total value of
bag and
contents 842.00
Reminders
IncludeInclude the following
the following items
items with
with your
your claim
claim
• Passenger• ticket
Passenger ticketfor
receipts receipts
each for each person
person involved
involved in loss
in this this loss
• 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 driver’s 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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