CAPITAL ONE

PURCHASE ASSURANCE CLAIM FORM

1 CAPITAL ONE MASTERCARD CARDHOLDER INFORMATION

CLAIM # 553258
Darcel A Collinson DATE: OCTOBER 11, 2016
116 - 6077 Kingsway
HOME PHONE: 604 568 5838
BURNABY, BC
V5J 5A6 MOBILE PHONE: 778 938 3460
EMAIL: TORONTOGIRL56@GMAIL.COM

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2 CLAIM INSTRUCTIONS
1. VERIFY THAT THE ABOVE INFORMATION IS ACCURATE AND MAKE PLEASE ATTACH THE FOLLOWING DOCUMENTS:
CHANGES WHERE REQUIRED.
▪ COPY OF YOUR MONTHLY STATEMENT CONFIRMING THE ITEM WAS CHARGED TO YOUR
2. COMPLETE THIS FORM IN FULL AND ATTACH ALL DOCUMENTS AS
REQUESTED. ACCOUNT
3. SIGN AND DATE COMPLETED FORM AND RETURN PACKAGE TO: ▪ ORIGINAL STORE RECEIPT DETAILING THE COST, DATE AND DESCRIPTION OF PURCHASE(S)
CAPITAL ONE MASTERCARD INSURANCE SERVICES ▪ COPY OF PAYMENT SHOWING DEDUCTIBLE AND PAID AMOUNT, OR LETTER DECLINING
SUITE 300, 901 KING STREET WEST RESPONSIBILITY TO PAY FROM ANY OTHER APPLICABLE INSURANCE
TORONTO, ON
M5V 3H5 ▪ IN CASE OF THEFT, POLICE REPORT OR OTHER CONFIRMATION OF LOSS
CANADA ▪ WRITTEN REPAIR ESTIMATE FOR ANY DAMAGED ITEMS
FOR CLAIMS INQUIRIES PLEASE CONTACT: +1 416-205-4357 OR
+1 888-324-2363.
PLEASE KEEP A COPY OF ALL THE SUBMITTED CORRESPONDENCE FOR YOUR RECORDS.
FAILURE TO COMPLETE THE CLAIM FORM AND ATTACH REQUESTED
DOCUMENTS WILL DELAY THE PROCESSING OF YOUR CLAIM.

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3 CLAIM DETAILS
YOUR CAPITAL ONE MASTERCARD CREDIT CARD NUMBER
FIRST 6 digits: | | | | | | | LAST 4 digits: | | | | |

DATE OF INCIDENT (DD/MM/YYYY) LOCATION WHERE INCIDENT OCCURRED

DD MM YYYY CITY/TOWN STATE/PROVINCE COUNTRY

TYPE OF INCIDENT c LOST c DAMAGED c STOLEN c OTHER (PROVIDE DETAILS)

WAS INCIDENT REPORTED TO THE POLICE? c YES c NO IF SO, PROVIDE REPORT NO: POLICE PHONE NO:

DESCRIPTION OF PURCHASES

DESCRIPTION OF ITEM MANUFACTURER MODEL PURCHASE PRICE

DESCRIPTION OF ITEM MANUFACTURER MODEL PURCHASE PRICE

DESCRIPTION OF ITEM MANUFACTURER MODEL PURCHASE PRICE

EXPLAIN HOW THE INCIDENT OCCURRED:

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4 CLAIM AMOUNT INFORMATION
TOTAL AMOUNT OF CLAIM $

TOTAL AMOUNT PAID BY OTHER INSURANCE (IF ANY) $ (PROVIDE SUPPORTING DOCUMENTATION)

OTHER INSURANCE INFORMATION

NAME OF HOMEOWNER OR CONTENTS INSURER TELEPHONE NUMBER POLICY NUMBER

HAVE YOU SUBMITTED YOUR CLAIM TO THIS INSURER? c YES c NO IF YES, INCLUDE A COPY OF THEIR SETTLEMENT.

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5 CERTIFICATION AND AUTHORIZATION
I CERTIFY THAT THE INFORMATION I PROVIDE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT THIS CLAIM SHALL BE VOID IF, WHETHER BEFORE OR AFTER THE LOSS, I
CONCEALED OR MISREPRESENTED ANY FACTS, OR IF ANY DOCUMENTS SUBMITTED HAVE CONCEALED OR MISREPRESENTED ANY FACT OR CIRCUMSTANCE CONCERNING THIS CLAIM.

I AUTHORIZE THE POLICYHOLDER, ITS AGENTS AND ADMINISTRATORS TO RELEASE TO THE INSURER, ITS AGENTS AND ADMINISTRATORS, ALL REQUIRED INFORMATION REGARDING MY CLAIM; AND I
AUTHORIZE THE INSURER, ITS AGENTS AND ADMINISTRATORS TO RELEASE TO THE POLICYHOLDER, ITS AGENTS AND ADMINISTRATORS, ALL REQUIRED INFORMATION REGARDING MY CLAIM. I
FURTHER AUTHORIZE THE INSURER, ITS AGENTS AND ADMINISTRATORS TO OBTAIN COPIES OF ANY INVESTIGATIVE REPORTS OR INFORMATION APPROPRIATE FOR THE PROCESSING OF THIS CLAIM.

I UNDERSTAND THAT THE INSURER IS REQUIRED TO COLLECT AND RETAIN CERTAIN PERSONAL INFORMATION ABOUT ME IN CONNECTION WITH MY INSURANCE COVERAGE. IT USES AND DISCLOSES
THAT INFORMATION ONLY FOR THE PURPOSE OF ADMINISTERING THE INSURANCE, PROVIDING CUSTOMER SERVICE AND INFORMATION PROVIDED IN CONNECTION WITH THIS CLAIM FOR THE
PURPOSES IDENTIFIED HEREIN. I HEREBY CONSENT TO THE USE OF THE PERSONAL INFORMATION ABOUT ME DISCLOSED IN ALL DOCUMENTS OR INFORMATION PROVIDED IN CONNECTION WITH THIS
CLAIM FOR THE PURPOSES IDENTIFIED HEREIN.

SIGNATURE: __________________________________________________________________ DATE: ______________________________________________

FOR COMPLETE COVERAGE INFORMATION, PLEASE REFER TO YOUR POLICY GUIDE AND CERTIFICATE OF INSURANCE.
10-11 ASSISTANCE AND CLAIMS SERVICES ARE PROVIDED BY WTP ASSIST
BENEFITS ARE UNDERWRITTEN BY AMERICAN BANKERS INSURANCE COMPANY OF FLORIDA*.