BAggAge LoSS CLAIM FoRM
Membership number ______________________________________________________________________________
Last name ______________________________________________ First name ______________________________
Home address ____________________________________________________________________________________
Host family name ________________________________________________________________________________
City _______________________________________________ State _____________ ZIP ______________________
Date you arrived in the U.S. _______________________________________________________________________
Date you expect to leave the U.S.___________________________________________________________________
Upgrade baggage coverage includes loss or damage of personal effects to a maximum of $1,000, while a participant
is on the AU pAIr In AmerIcA program. There is a per occurrence deductible of $100 and a per item limit of $100
(except $250 for cameras). coverage is for the value at the time of the loss, not the original purchase price.
The following exclusions apply: loss of money, notes, securities, tickets and documents (driver’s licenses, passports,
passes, etc.); jewelry, watches, computers, articles consisting in whole or in part of silver, gold or platinum and furs;
animals, automobiles, automobile parts and equipment, motorcycles, skis, bicycles, boats, motors or other convey-
ances or their appurtenances, household furniture, artificial teeth and limbs; any kind of glasses (including sunglasses)
and contact lenses; breakage of articles of a brittle nature unless caused by thieves; fire or accident to conveyances;
loss or damage caused by, or resulting from, declared or undeclared war; seizure or destruction under quarantine
or customs regulations; confiscation by order of any government or public authority, risk of contraband or illegal
transportation or trade; loss due to wear, tear, gradual deterioration or negligence on the part of the Insured.
proof of loss or damage in the form of a police report or report filed with an airline, railroad, bus operator, hotel,
motel, or host family, etc., is required and must be attached to this claim form. If a transportation company or lodg-
ing provides loss or damage coverage, you must claim against them first and attach their response to this claim.
please list items lost or damaged, with their date of purchase and estimated value at the time of the loss. Include
brand and model numbers as appropriate. Attach receipts for items listed. Use the reverse of this form if additional
space is required. Settlement may be by check, or replacement with a comparable article of similar value. If settle-
ment cannot be made prior to your departure from your host family, cultural Insurance Services International (cISI)
will forward settlement and/or correspondence to the home address you entered above. please advise if you wish
settlement payable in the currency of your home country.
Kind of loss: ❑ Theft ❑ Fire ❑ Accident ❑ Other (explain)
Total amount of loss: $____________
How did the loss or damage occur? Include date, time, place and full details as to whom in authority you reported the
I certify that the information furnished by me in support of this claim is true and correct.
Mail this claim to: Baggage Claims Department, Cultural Insurance Services International,
River Plaza, 9 West Broad Street, Stamford, CT 06902-3788, USA