Property Damage, Personal Injury, or Wrongful Death

Use this form if you suffered property damage, personal injury, or wrongful death AND you believe it was caused by the security screening N2 performed at one of the airports below. If the loss was caused by your airline, file directly with the air carrier.

Airports served: airport code(s) & name(s) for this task order

To validate this claim, it must include all five:

Sum certainAn exact U.S. dollar amount in the Amount of Claim section.

Specific dateThe specific date of the alleged incident.

Specific locationWhere the incident occurred.

Statement of factA detailed, factual account — names, places, events.

SignatureA full legal signature; without it the claim is not processed.

To expedite your claim, include:

Purchase receipt of the original item (or card/bank statement)
Boarding passes for the date of loss
Repair estimates (required for damaged baggage)
Replacement estimates (if not repairable)
Photographs of lost/damaged items
Police, witness, or incident reports
Air carrier / other company claim reports
Original Notice of Inspection (checked baggage)

I have read and understand the instructions for filing a claim.

Claimant Details

Full name *

Phone number *

Email address *

Address *

City *

State *

ZIP code *

Country *

Description of self to assist with locating on camera *

Description of traveling companion(s), if applicable

Claimant's Representative

Complete this step only if someone is filing on the claimant's behalf (agent, attorney, parent, guardian, executor). A representative must file in the name of the claimant and show their authority to act.

Representative full name

Relationship / capacity

Phone number

Address

City

State

ZIP code

Country

Claim Details

Date of incident *

Time of incident *

Airport *

Where did it occur? *

Travel itinerary

Airline

Flight number(s)

Departure time(s)

Arrival time(s)

Did you use a Skycap, porter, or third-party baggage service?

Yes No

Basis of claim — statement of fact *

Property damage / loss

Owner of the property, if other than claimant

Describe the property, nature and extent of damage, and where it can be inspected

Personal injury / wrongful death

Nature and extent of each injury or cause of death (name the injured/decedent if not the claimant)

Incident reports & insurance

Did you file an incident report with the airline, airport, TSA, N2, or law enforcement?

Yes No

Do you carry liability, property, or accident insurance?

Yes No

Amount of claim (sum certain, U.S. dollars)

Property damage / loss

Personal injury

Wrongful death

Total claim *

Witnesses

List anyone who witnessed the incident. Optional, but helpful to the investigation.

Witness 1

Full name

Address / phone / email

Witness 2

Full name

Address / phone / email

Witness 3

Full name

Address / phone / email

Attachments

Claimants upload supporting files here. file-upload +

Proof of travel (boarding pass / ticket / luggage tag)

Original Notice of Inspection (checked baggage)

Purchase receipt / card or bank statement

Repair estimate (required for damaged baggage)

Replacement estimate(s)

Photographs of lost/damaged items

Police / witness / incident reports

For injury: physician report & itemized bills

Review & Submit

I certify that the amount of this claim covers only the damages and/or injuries resulting from the incident described above, and I agree to accept that amount in full satisfaction and final settlement of this claim.

Legal signature of claimant *

Date of claim *

Fraud / false-statement Notice -- Verify compliance with each state.

I acknowledge that I have read and understand the instructions, and that the information provided is true and complete.

Submission is disabled in this template.

File a Claim

Property Damage, Personal Injury, or Wrongful Death

To validate this claim, it must include all five:

To expedite your claim, include:

Claimant Details

Claimant's Representative

Claim Details

Witnesses

Attachments

Review & Submit