
PASSENGER PROPERTY QUESTIONNAIRE
AAdvantage or US Dividend Account: ________________ Record Locator or File Reference Number: ________________
Type of Claim: (check all that apply)
Lost Luggage
Missing Contents
Damaged Luggage and/or Contents
Delay Expenses
Mr. First Middle Last Name
Mrs.
Ms.
Phone Number
Home: Business:
Permanent Mailing Number Street Apt.
Address
Temporary Mailing Number Street Apt.
Address
City State
Zip Code
City State
Zip Code
Country
Postal Code
Country
Postal Code
Email Address: Employed by:
Occupation:
Your Complete Flight Itinerary
From To Airline Flight Number Travel Date
Have you, or any member of your household, had a previous baggage claim with AA/US or any other airline in the last 5 Years? Yes
No
If yes, list each airline, claimant name and dates (attach an additional page if necessary)
Airline(s) __________________________________________________ Name(s) __________________________________________________
Date(s) _______________________________________________________________________________________________________________
Information gathered on this form may be shared with other airlines, local, state and federal law enforcement agencies or private insurers.
Number of ticketed passengers
traveling in your party:
Number of passengers
claiming missing baggage:
Purpose of trip? Length of stay?
Were you charged for excess
and/or overweight baggage:
Yes
No
Did you declare and pay for excess value: Yes
No
Value declared: $
Have you received your baggage and are you missing contents only: Yes
No
If yes, how many bags are missing contents?
No
In person
Where and when did you last see your baggage?
Has this loss been reported to another airline? Yes
No
If yes, please provide name of airline and city where reported.
APPLICABLE IN USA ONLY. It is expressly understood and agreed by the claimant that the furnishing of this form and any assistance given by employees of
American Airlines, Inc., are acts of courtesy and shall not constitute a waiver of any rights or an admission of liability by or on the part of American Airlines, Inc., its
employees or agents. Any other information and/or documents relating to this statement which are required by American Airlines, Inc., will be furnished by claimant
upon request and shall be considered part of this statement.
and any
such claims received by American Airlines, Inc., are reported to the United States Postal Authorities. Loss of baggage in interstate shipment or of articles from such
by the Federal Bureau of
Investigation.
OP124 (Rev 11/2013) CPN 5689520 Complete Reverse Side