Baggage Declaration Form

Dear Customer,

We regret your baggage did not arrive with you at your final destination. In the unlikely
event that your baggage has not been returned to you within 5 days of your arrival,
please fill out this contents list and attach it at the end of the online webform in the
below link, or post to the following address:
https://help-aircanada.com/aircanada-help/createIssue.do?lang=ENU

Air Canada Baggage Claims

Air Canada ZIP 1116
P.O. Box 8000, station Airport
Dorval, Quebec
H4Y 1C3
A description of the contents of your missing baggage as detailed as possible will help
us to find it. If you are missing several pieces of baggage, please complete a separate
list for each missing bag.

PLEASE INCLUDE ALL AIRLINE TICKETS, BAGGAGE CLAIM TAGS, AND

RECEIPTS. ALL ITEMS CLAIMED MUST SUBSTANTIATED IN YOUR CLAIM.
PLEASE ATTACH A PHOTOCOPY OF A SIGNED PHOTO IDENTIFICATION.

All claim must be made in writing within 21 days of your arrival. The report made at the
airport is only an incident report and will not initiate a claim.

Thank You.
 BAGGAGE DECLARATION

Baggage Tracing Number : (ex. Y ULAC12345) ___________________________________________________________________

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 is now missing and for which this c laim is made.

COMPLETE ITNERARY
From To Airline Flight number Full date

1. Number of persons travelling together:____________________Infants (under age 2)________________________________________

Ticket numbers:_________________________________________________________________________________________________

2. Total number of bags checked ____________Number of bags received:__________ Number of bags missing: __________________

3. Claim check numbers:_____________________________________________________________________________________________

4. Weight of missing bag(s) 1.______(lb / kg) 2._____(lb / kg) 3. _____(lb / kg) 4.______(lb / kg)
5. Were you charged for “Excess Baggage”?___________________ _ __Amount paid:__________________________________________
(Attach receipt)
6. Did you declare “excess valuation” and purchase additional coverage?_____ Value declared:________________________________
Amount paid :________________________________________________ (Attach receipt)

7. Was there a name and address label on the bag(s)______________ if so, what did it show __________________________________
8. Was there any other identification on the bag(s)? (i.e. tags, stickers, ribbons)?_____________________________________________
9. Was loss reported?______________Time______________Date______________By phone or in person__________________________
To which airline?___________________________Where was it reported?_________________________________________________
If the missing baggage was not reported immediately upon arrival, indicate the reason for the delay:
________________________________________________________________________________________________________________
Are you pursuing this claim with another carrier?_____________Indicate the carrier’s name__________________________________

10. Was your baggage rerouted or rechecked enroute? _ _________ Where? __________________________________________________
Why? __________________________________________________________________________________________________________
By which airline? _______________________________________ New tag numbers: ________________________________________

11. Where and when did you last see the baggage that is the subject of this claim? ____________________________________________

12. Was the baggage that is the subject of this claim cleared through Customs? _____________________________________________
If so, where? ________________ Were the contents inspected? ________________________________________________________
After clearance, where was the baggage placed?____________________By whom? ________________________________________

13. Do you have any insurance coverage for the missing items? _________________________________________________________
Will you be submitting a claim to your insurer?___________________________________________________________________
Name / Address of insurance company ________________________________________________________________________________

14. Other relevant information or comments: ___________________________________________________________________________

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 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 _________________________________

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: ______________________

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ATTACH YOUR AIRLINE TICKET(S)/BAGGAGE CLAIM CHECK’S AND EXCESS BAGGAGE RECEIPTS (IF APPLICABLE)

RECEIPTS FOR ALL ITEMS CLAIMED MUST BE ATTACHED

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 ITEMIZED LIST AND DESCRIPTION OF BAGS AND CONTENTS
• Please identify bag/article type on Airline Baggage Identification Chart (see page 6)

• Please ensure that you provide a complete itemized list of all contents in your baggage.
Please be specific and use common terminology (e.g. shirt, sweater, turtleneck, blouse,
dress, skirt, trousers, sweatpants, jeans).

P A P I

QTY Article Size, Color, Brand, Male Date of City/Store Original

Manufacturer, Serial Female Purchase Where Purchase Price
Number (s) etc. Infant purchased
(M/F/I)

If more than one bag involved, please list contents of each additional bag on a separate sheet.

TOTAL AMOUNT CLAIMED If possible, show in Canadian or US Dollars

(If applicable, show rate of exchange.) . $___________________

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 Airline Baggage Identification Chart

Circle appropriate item and supply Brand, Color and Size descriptions
Circle any descriptive elements (pockets, wheels, etc.)

BRAND NAME __________________________________________________________________

COLOUR __________________________________________________________________

SIZE ____________________________ZIPPERED YES θ NO θ

DESCRIPTION __________________________________________________________________

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 DOCUMENT CHECKLIST

Did you enclose:

θ Airline Ticket(s) / E-Ticket/Itinerary

θ Baggage Claim Check(s)

θ Boarding Pass

θ Original Purchase Receipts

θ Itemized list for each additional bag

θ Photocopy of signed photo identification