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Claim form for

Trip Cancellation & Interruption Protection

Sorry to hear that you had a problem with your trip. We appreciate your business and hope Return this form and all
we can help. We’ll process your claim quickly and let you know if it’s eligible for benefits supporting information
under Trip Cancellation & Interruption Protection. required to:
By mail
To file a claim, return this claim form or call 1-866-918-4670 within 60 days of cancellation,
Virginia Surety Company
interruption or reasonable extension of your trip. PO Box 87719
Failure to file a claim within 60 days will result in the denial of coverage. When returning Chicago, IL 60680-0919
this claim form, enclose copies of the supporting documents you have available and retain the
By fax
originals for your records. Once the claim has been filed, return all requested documents within
1-312-395-9501
180 days of the cancellation, interruption or reasonable extension of the trip. Please write your
name and the last four digits of your card number on all enclosures, and make sure they‘re By email
legible to avoid any delay in processing your claim. You can expect to hear back from us within mybenefits@
two weeks after we receive all requested information. cardbenefitscommunications.com

Supporting documents required (Check and enclose all that apply.)

Billing statement or ticket receipt showing
how much you paid
Your itinerary from the common carrier
Proof of non-refundable fees or other
expenses from the common carrier or
other provider
Proof of expired voucher or credit with
the common carrier
Need our help?
Proof of reason for cancellation (doctor’s
Call the Citi card benefit servicing
note, death certificate, police report, etc.) center, seven days a week.
The common carrier’s completed claim 1-866-918-4670
report
Benefits statement from your other
insurance company, if processed already

Cardmember information

Name Last four digits of card number

Address

Primary phone number Alternate phone number

Email

About the incident

Date ticket was purchased Common carrier name

Amount charged to card $ Number of rewards points redeemed

Departure date Completion date Date of incident

Description of what happened

Page 1 of 3 Citi card protection benefits are provided by Virginia Surety Company 09.01.2018 CFTC001
About your nonrefundable expenses

Total amount of reimbursement requested $

Item/Expense Amount Item/Expense Amount

$ $

$ $

$ $

$ $

$ $

$ $

Attach a second page if you need to list additional expenses.

Insurance information required

The coverage provided by this benefit is secondary. This means if you have another insurance
policy that will reimburse you, this benefit will cover only the amount that the other insurer or the
common carrier does not.

Did you file a claim with the common carrier?

YES Date and location claim submitted

Amount received, if any $

NO Why not?

Do you have any other insurance that may cover this loss?

NO

YES Insurance company

Policy number Date claim submitted to this company

Deductible $ Amount received, if any $

Page 2 of 3 Citi card protection benefits are provided by Virginia Surety Company 09.01.2018 CFTC001
For your protection the following statement is contained in this
document. Any person who knowingly, and with intent to injure, defraud,
or deceive any insurer, presents a false or fraudulent claim for payment
of a loss or benefit is guilty of a crime and may be subject to denial of
insurance benefits, fines and confinement in prison.
By signing below, you:
• Certify that all information you provided on For New York only: Any person who knowingly
this form is true and correct to the best of and with intent to defraud any insurance
your knowledge; company or other person files an application for
• Authorize Virginia Surety Company, Inc., TWG insurance or statement of claim containing any
Innovative Solutions and all their authorized materially false information, or conceals for the
representatives to verify all information and purpose of misleading, information concerning
documentation you provide; and any fact material thereto, commits a fraudulent
insurance act, which is a crime, and shall also
• Acknowledge that you have read the Guide to
be subject to a civil penalty not to exceed five
Protection Benefits that govern this benefit
thousand dollars and the stated value of the
and understand the coverage being afforded
claim for each such violation.
to you.
For Oregon only: Any person who knowingly, and
Your claim submission does not waive any with intent to injure, defraud, or deceive any
condition or use of the master policy. insurer, presents a false or fraudulent claim for
For Florida only: Pursuant to § 817.234, payment of a loss or benefit may be guilty of a
Florida Statutes, any person who, with the crime and may be subject to denial of insurance
intent to injure, defraud, or deceive any insurer benefits, fines and confinement in prison.
or insured, prepares, presents, or causes to be
For Pennsylvania only: Any person who
presented a proof of loss or estimate of cost
knowingly and with intent to injure or defraud
or repair of damaged property in support of
any insurer files an application or claim
a claim under an insurance policy knowing
containing any false, incomplete or misleading
that the proof of loss or estimate of claim
information shall, upon conviction, be subject
or repairs contains any false, incomplete, or
to imprisonment for up to seven years and
misleading information concerning any fact or
payment of a fine of up to $15,000.
thing material to the claim commits a felony
of the third degree, punishable as provided in
§ 775.082, § 775.083, or § 775.084, Florida
Statutes.

Signature Date

How would you like us to issue your reimbursement?

Credit my Citi card account

Mail me a check

Si necesita ayuda para entender la información contenida en este documento, por favor
llame al 1-866-918-4670, donde podrán brindarle una aclaración y asistirle.
If you need help understanding the information contained herein, please call 1-866-918-4670
for further clarification and assistance.

Page 3 of 3 Citi card protection benefits are provided by Virginia Surety Company 09.01.2018 CFTC001