INTERIM EXPENSES
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.
Air Canada Baggage Claims
Air Canada ZIP 1116
P.O. Box 8000, station Airport
Dorval, Quebec
H4Y 1C3
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 : ( ex. YULAC1 234 5 )
_ __ __ __ __ ___ __ __ __ ___ __ __ __ __ __ __ ___ __ __ __ ___ __ __ _
I , Mr. / Mrs. / Ms.
________________________________________________________________________________________________
( Family Name/ s)( Given Name/ s)
________________________________________________________________________________________________________
(Name as indicated on Passport if different from above)
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 I TNERARY
1.Number of persons travelling together: __________________ I nfants (under 2 years) _____________________
Ticket numbers __________________________________________________________________________________
2.Total number of bags checked ___________________________________________________________________
3.Claim check or tag numbers_____________________________________________________________________
4. Were you charged for Additional Checked Bagage?________ 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 identificat ion 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?_______________________________________
I f 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? ____________________________
I f 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)
Frequent Flyer ID : ___________________________________
Date of Birth : _____________________________________
(Optional)yy/mm/dd
Residence Address :
________________________________________________________________________
________________________________________________________________________
Residence Tel: (____)___________________________
Cell: (____)____________________________________
E-Mail : _____________________________________________________________________
Company Name :
________________________________________________________________
Business Address :
________________________________________________________________
Business Tel.:
(____)___________________________________________________________
Any prior address (within past 2 years):
_________________________________________________
_________________________________________________________________
Prior Tel.:
(____)____________________________________________________________
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
_________________________________
3
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.
Claimant’s Signature ________________________________________ Date: __________________
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
Size, Color,
Brand,
Manufacturer,
Serial Number (s)
etc.
Male
Female
Infant
(M/F/I)
City/Store
Where
purchased
If possible, show in Canadian or US Dollars. (If applicable, show rate of exchange)
