VMD Claim for Damage, Loss, Personal Injury or Death
What are you reporting?
*
Property Damage
Property Lost
Injury
Death
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Basis of Claim
State in detail the known facts and circumstances regarding the damage, injury, or death, identifying persons and property involved, the place of occurrence and the cause thereof.
*
Property
Description of Property Damaged and/or Lost (include brand names, model numbers, etc.):
*
Describe Nature and Extent of Damage Claimed:
*
How Did Damage / Loss Occur (if known):
*
Personal Injury/ Wrongful Death
State the nature and extent of each injury or cause of death, which forms the basis of the claim. If other than the claimant, state the name of the injured person or decedent.
*
Witnesses
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Other Information
Have You Also Filed a Claim for this Incident with Your Insurance Company? Yes No(If “Yes”, List Name and Address of Insurance Carrier):
*
Yes
No
List Name and Address of Insurance Carrier
Airport where the incident occurred:
*
Location of Incident:
*
Date of Incident:
*
-
Month
-
Day
Year
Date
Time of Incident:
*
Airline
*
Original Flight Number
*
Scheduled Departure Time
*
Departure Gate
*
Final Destination (Airport)
*
Intermediate Airport(s)
Name or Badge No# of Security Officer(s) Involved if Known:
Did you Notify Anyone at the Time of the Incident?
*
Yes
No
If Yes, List Name and Affiliation (airline, police, security, etc.):
USE THE SPACE BELOW TO EXPAND ON ANY OF THE ABOVE BLOCKS AND/OR TO INCLUDE ANY OTHER INFORMATION
Amount you are claiming (USD)
Property Damage/Loss
Personal Injury
Wrongful Death
Total
Attach documentation regarding your specific loss/damage claim.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Acknowledgment
*
I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that knowingly presenting or making a false claim may subject me to criminal prosecution.
Submit
Should be Empty: