Claim ID: 7107415 Claim Type: TRD Plan Number: F200B

From: Trip Mate, Inc.

PO BOX 527,
Hazelwood, MO 63042

In CA & UT, dba Trip Mate Insurance Agency

1-844-777-6859 (Toll-Free) Fax: * E-mail: mail@travelclaimsonline.com

To: Lisa Tejeda

534 Washington Street 3w
Allentown PA, 18102

Enclosed are the claim forms for the claims you have reported. Please
review each form and complete any information that may be missing.

After completion, sign each form where indicated and return with all
documentation (see instruction page).

You may review the status of your claim online at www.tripmate.com

by entering your Name, Plan Number and the Claim ID listed above.
Claim ID: 7107415 Claim Type: TRD Plan Number: F200B

Travel Delay Claim Form

HOW TO COMPLETE YOUR CLAIM FORM
Read the claim form carefully, answer all questions as completely as you can and provide all required documentation.
Please be sure to sign where indicated. Following are some important guidelines for completion of the form:

The information requested under “Trip Information” will help us confirm your purchase of the plan. Check your travel
documents to ensure that the information on your form is correct.

The "Information About Your Travel Delay" section will give us details about your travel delay. After completing this
section, you need to complete only the part(s) that applies to your circumstances.

• If you are seeking reimbursement due to delay or cancellation of an air flight, you will need to provide the
flight delay information requested on Page #2.

• For reimbursement of additional expenses incurred due to a travel delay, you will need to provide the additional
expense information requested on Page #2.

REQUIRED DOCUMENTATION:

Payment Information - a copy of your trip itinerary and copies of all invoices, credit card statements and/or
canceled checks evidencing your payment for the trip.
Additional Expenses - any documentation of expenses for which you are requesting reimbursement on Page
#3 such as: tickets, receipts, and bills (retain originals for your records).
Cause of Your Travel Delay - any documentation substantiating the reason for your travel delay.

Before returning your claim form, please review the form to make sure all of the information provided is accurate and
complete and that all required documentation is included. Should you have any questions concerning the completion
of this form, please contact our Customer Service Department at the toll-free number below.

Trip Mate, Inc. PO BOX 527, , Hazelwood, MO 63042

1-844-777-6859 (Toll-Free) Fax: * E-mail: mail@travelclaimsonline.com

In CA & UT, dba Trip Mate Insurance Agency

TRD-A-02-14
 Claim ID: 7107415 Claim Type: TRD Plan Number: F200B

Travel Delay Claim Form

TRAVELER INFORMATION
Gender Date of Birth
Lisa Nicole Tejeda
Name 1 _____________________________________________________________ M F X 12 / ___
___ 5 / 1995
___
Prefix First Middle Last Suffix

534 Washington Street 3w

Mailing Address _______________________________________________________ Daytime Telephone # ( 809 ) _____
696 __________
2044
Street Address

Allentown PA USA 18102

____________________________________________________________________ Evening Telephone # ( 786 ) _____
323 __________
7817
City State/Province Country Postal Code

Preferred Contact Number Day X Evening

Below, please enter the Name, Gender, Date of Birth and Relationship to Name
1 of other persons in the household who have a claim. Gender Date of Birth Relation to Name 1

Name 2 _____________________________________________________________ M F ___ / ___ / ___ ______________

Prefix First Middle Last Suffix

Name 3 _____________________________________________________________ M F ___ / ___ / ___ ______________

Prefix First Middle Last Suffix

Name 4 _____________________________________________________________ M F ___ / ___ / ___ ______________

Prefix First Middle Last Suffix

TRIP INFORMATION
Attach a copy of the front and back of your canceled check or a copy of
Date You Purchased Protection Plan ___ / ___ / ___ your credit card statement showing your protection plan purchase.
Fareportal, Inc.and its affiliates (dba CheapOair, CheapOstay,
Name of Tour Operator/Cruise Line/Travel Agency_____________________________________________ Fare Buzz,Travelspot
Booking/Invoice and Insanelycheapflights
#______________
Dominican Republic
Tour/Cruise Name and Number ________________________ Primary Trip Destination(s) __________________________________________
4 / ___
Scheduled Trip Information: Scheduled Trip Departure Date ___ 1 / ___
2022 6 / ___
Scheduled Trip Return Date ___ 30 / 2022
___
Miami
Trip Departure City ____________________________ Santo domingo
Trip Return City ____________________________
2 / ___
Date of Initial Deposit for Trip ___ 7 / 2022
___ Date of Final Payment for Trip ___ / ___ / ___

Did you book through a travel agent/agency? X Yes No Cheapoair

If yes, Agency Name ____________________________________________
Cheapoair Cheapoair
Agent Name ___________________________ Telephone No. ( 809 ) _____
696 __________
2044 nicol_tejeda@hotmail.com
E-mail Address _________________________

Is there any other insurance or protection plan covering this trip? Yes X No If yes, Policy or Plan No. ____________________

Name of other insurer__________________________________ Telephone No. ( ) _____ __________ Claim No. _________________

INFORMATION ABOUT YOUR TRAVEL DELAY

4 / ____
Dates travel not possible: From ____ 1 / ____
2022 to ____
4 / ____
3 / ____
2022

Your delay was the result of (check appropriate box):

X Carrier delay or cancellation
Circumstances other than carrier delay or cancellation (Describe reason(s) below)

TRD-USA-A- 02-14

1-844-777-6859 (Toll-Free) Fax: * E-mail: mail@travelclaimsonline.com Page 1 of 3

Claim ID: 7107415 Claim Type: TRD Plan Number: F200B
If your travel delay was due to a carrier delay or cancellation, please complete:

Scheduled departure time: 10 46

____:____ AM X PM Scheduled departure date: 4 / ____
____ 1 / ____
2022

Actual departure time: 8 35

____:____ AM X PM Actual departure date: 4 / ____
____ 3 / ____
2022
Reason for delay/cancellation _______________________________________________________________________________________
american airlines
Name of carrier ______________________________________ AA 972
Flight / Train / Bus # __________________
miami
From _____________________________________________ santo domingo
To __________________________________________________
City City
Please provide documentation of your carrier delay or cancellation.

If you incurred additional local transportation / hotel expenses due to the travel delay, please complete:

Additional Local Transport Expenses:

uber
Name of Carrier ____________________________________________________ 4 / ____
Date of service: ____ 1 / ____
2022

miami airport
Departed from: ________________________ 335 ne 35th st, miami fl, 33126
to ___________________________ 35.00
Fare: $ _______________________

lyft
Name of Carrier ____________________________________________________ 4 / ____
Date of service: ____ 2 / ____
2022
miami
Departed from: ________________________ miami airport
to ___________________________ 25.00
Fare: $ _______________________

lyft
Name of Carrier ____________________________________________________ 4 / ____
Date of service: ____ 2 / 2022
____
miami airport
Departed from: ________________________ coral gables
to ___________________________ 24.35
Fare: $ _______________________

Additional Land Accommodation Expenses:

Name and address of hotel, motel: ____________________________________________________________________________

Dates of Stay from: ____ / ____ / ____ to ____ / ____ / ____ Amount paid: $ _________________

Name and address of hotel, motel: ____________________________________________________________________________

Dates of Stay from: ____ / ____ / ____ to ____ / ____ / ____ Amount paid: $ _________________

Additional Meal Expenses:

4 / ____
Date: ____ 2022 Name of hotel, restaurant, etc. ______________________________
3 / ____ xochimex cantina grill 32.00
Amount paid: $ _____________

Date: ____ / ____ / ____ Name of hotel, restaurant, etc. ______________________________ Amount paid: $ _____________

Date: ____ / ____ / ____ Name of hotel, restaurant, etc. ______________________________ Amount paid: $ _____________

Date: ____ / ____ / ____ Name of hotel, restaurant, etc. ______________________________ Amount paid: $ _____________

Date: ____ / ____ / ____ Name of hotel, restaurant, etc. ______________________________ Amount paid: $ _____________

Date: ____ / ____ / ____ Name of hotel, restaurant, etc. ______________________________ Amount paid: $ _____________
$ 173.66
Total Amount Being Claimed: $ ________________

Provide documentation (i.e. tickets, receipts, bills, etc.) for all of the above expenses.

Trip Mate, Inc.

PO BOX 527,
Lisa Tejeda
Hazelwood, MO 63042
534 Washington Street 3w
Allentown PA, 18102 In CA & UT, dba Trip Mate Insurance Agency
1-844-777-6859 (Toll-Free) Fax: * E-mail: mail@travelclaimsonline.com
Page 2 of 3
 Claim ID: 7107415 Claim Type: TRD Plan Number: F200B

Important Information (Please read and sign)

Fraud Warning: Any person who, with the intent to defraud or knowingly facilitates a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement, or conceals information for the purpose of misleading may be
guilty of insurance fraud and subject to criminal and/or civil penalties.

Notice To Pennsylvania Claimants: Any person who knowingly and with intent to defraud any insurance company or other person
files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects
such person to criminal and civil penalties.

To determine eligibility for claim benefits, claim payment amounts, and identification and prevention of potential fraudulent activity,
the insurance company(ies) underwriting your policy, or its representatives, may disclose the claims information submitted to the
insurance company(ies), or its representatives, to any insurance support organization or fraud information clearinghouse utilized by
the insurance company(ies), or its representatives.

** ATTENTION: IF YOU ARE CLAIMING AIRLINE TICKETS, PLEASE COMPLETE THE BELOW. **

Your airline tickets may have value for up to one year from the original scheduled travel date. Please indicate below whether you
will be exchanging your ticket for another trip. Please note: Your signature on this agreement is not a guarantee of payment. All
final claim determinations are subject to eligibility and the terms of the policy.

___ I (We) will not be using our airline ticket(s). (Please include a copy of your electronic ticket confirmation(s) which includes your
ticket number(s).)

___ I (We) will be exchanging our airline ticket(s) for future travel. (Please submit documentation of the cost you incurred or will
incur to exchange your ticket(s).)

___ I (We) did not purchase airline ticket(s) in conjunction with the travel arrangements for which I (We) are submitting this claim.

Please review the claim form to make sure all of the information provided is accurate and complete and that
all required documentation is included and sign below.

All statements contained in this form are true and complete to the best of my knowledge.

Date Completed: ____ / ____ / ____ Your Name: ____________________________________________

Your Signature: _________________________________________

FR- 02-14

Trip Mate, Inc.

PO BOX 527,
Lisa Tejeda
Hazelwood, MO 63042
534 Washington Street 3w
Allentown PA, 18102 In CA & UT, dba Trip Mate Insurance Agency
1-844-777-6859 (Toll-Free) Fax: * E-mail: mail@travelclaimsonline.com
Page 3 of 3
Claim ID: 7107415 Claim Type: TRD Plan Number: F200B

Additional Information

ADDITIONAL LAND TRANSPORTATION EXPENSES

uber D: 4/3/2022 From: coral gables To: 7368 SW 80TH ST PLZ, miami,fl 33143 $ 14.69
uber D: 4/3/2022 From: 7368 SW 80TH ST PLZ, miami,fl 33143 To: 7368 SW 80TH ST PLZ, miami,fl 33143 $
42.62