Air Canada Claims Form

AIR CANADA INTERIM EXPENSE CLAIM FORM

Please complete this form if your baggage was delayed and returned to you, and you are now claiming for expenses incurred while your bag was not in your possession.

If you live in North America, the completed form should be mailed to our Montreal office at the address below. Residents of other countries should send it to the closest Air Canada office.

PLEASE INCLUDE ALL AIRLINE TICKETS, BAGGAGE CLAIM CHECKS AND EXCESS BAGGAGE RECEIPTS (if applicable). PURCHASE RECEIPTS FOR ALL ITEMS CLAIMED MUST BE ATTACHED TO SUBSTANTIATE YOUR CLAIM. PLEASE ATTACH A PHOTOCOPY OF A SIGNED PHOTO IDENTIFICATION.

If you have homeowner/household, baggage or credit card insurance against which you may claim, please complete question #10 below.

Your claim must be made in writing within 21 days of your arrival. This completed and signed Interim Expense Form is the official written notice of a claim. The report made at the airport is an incident report only. All claims will be processed as quickly as possible.

The Conditions of Contract on your ticket/e-ticket itinerary refer to limitations of liability based on tariffs, and/or the Warsaw Convention and/or the Montreal Convention. These amounts are not automatically payable but reflect what the maximum compensation might be, as each claim is subject to proof of loss.

Please note that special rules apply to fragile and perishable items and that consequential damages such as loss of enjoyment, loss of business, inconvenience, etc. are not compensable. Please also note that for domestic travel within Canada, or for any travel where none of the aforementioned Conventions apply, airlines are not liable for the loss of money, jewelry, silverware, samples, business documents, electronic equipment or other valuable articles, under any circumstance.

Thank you for your cooperation and understanding.

INTERIM EXPENSE CLAIM FORM

Baggage Tracing Number:

do solemnly declare that on the day of year I checked baggage belonging to which was delayed by the airline(s) and for which this interim expense claim is made.

COMPLETE ITINERARY

1. Number of persons travelling together: Infants (under 2 years)

Ticket numbers

2. Total number of bags checked

3. Claim check or tag numbers

4. Were you charged for Additional Checked Baggage? Amount paid (Attach receipt)

5. Did you declare “excess valuation” and purchase additional coverage? Value declared Amount paid (Attach receipt)

6. Was there a name, address or any other identification on the bag(s)? (i.e. tags, stickers, ribbons)

7. Was the loss reported? Time Date

By phone or in person? To which airline?

Where?

If the missing baggage was not reported immediately upon arrival, state the reason for the delay

Are you pursuing this claim with another carrier? Carrier?

8. Was your baggage rerouted or rechecked en-route? Where?

Why?

By which airline? New tag numbers

9. Was the baggage for which this claim is being made, cleared through Customs?

If so, where? Were the contents inspected?

After clearance, where was the baggage placed? By whom?

10. Do you have any insurance covering the delayed items?

Name / Address of insurance company

Will you be claiming from them?

11. Other relevant information or comments

PLEASE ATTACH A PHOTOCOPY OF A SIGNED PHOTO IDENTIFICATION (MANDATORY)

Have you or any member of your household ever had a previous claim with Air Canada or any other airline? YES NO

If yes, give name of carrier and date

For the purpose of tracing your baggage as well as processing and verifying your claim, it is sometimes necessary to disclose personal information that you have provided us relating to your claim into a baggage tracing and/or claims database, which is accessible to other participating airlines and handling agencies.

By signing the declaration below you consent to this disclosure.

I make this solemn declaration conscientiously believing it to be true and knowing that it is of the same force and effect as if made under oath. I understand this declaration may be subject to review and investigation and I hereby give Air Canada the authority to require from anyone any documents or statements in relation to this declaration.

According to section 131 and 132 of the Criminal Code, any person who makes a solemn declaration knowing that the declaration is false, is guilty of an indictable offense and may be liable for imprisonment for a term not exceeding fourteen years. Similar laws are applicable in other countries. I also understand that Air Canada may disallow any claim for loss, which contains misrepresentations, including false statements concerning whether or not previous claims have been made with Air Canada or other carriers.

LIST OF ITEMS CLAIMED AS INTERIM EXPENSES

• Please ensure that you provide a complete list of all items purchased as interim expenses while you were not in possession of your bag and attach all original purchase receipts