Marine Accident Claim

Insured

Insured First Name *
Insured Last Name *
Insured Contact *
Insured Contact E-Mail *
Insured Address (line 1)
Insured Address (line 2)
Insured Address (line 3)
Insured Tel (Work)
Insured Tel (Home)
Insured Tel (Cell)
Insured Policy No
Insured Vat No
Exact Type of Vessel
Vessel Reg No
Please leave this field empty.

Incident Details

Date of Incident
Time of Incident
Location of Incident
Wind Speed
Wind Direction
Sea Conditions ---ClamModerateRoughStorm
Speed in Knots
Person in Control
Years Experience
Qualifications
Number of People
Ships Purpose ---PrivatePleasureSkipperCharterBareBoatCharter
Cause ---TheftFireCollisionGroundingSinkingStormDamageWindDamageWaterDamageMachineryDamageNegligenceMaliciousDamageAccidentalDamage
Activity ---MooredRepairer`sYardUnderwayRoadTransitOnTowRacing/Understarter`sordersAnchoredLaidupAshoreLaidupAfloatDemoWaterskiingBerthing/Docking
Brief Accident Summary
Claimed Loss ---Total/ConstructiveLossMachineryDamageMast,Spars,Rigging,SailsTrailerOutboardMotorThirdPartyLiabilitySalvageHullDamagePropeller/ShaftonlyTender/DinghyPersonalEffectsEquipmentKeel/RudderPersonalAccident

Third Party Details

Bodily Injuries Details
Nature and Extent of Damage
Do You Accept Liability ---YesNo
Details
Were You At Fault ---YesNo
Reason
Policy Details

Persons Notified

Officials Notified
Details of Notified Person
Contact Number of Notified Person
Reference Number of Notification

Police

Was Stolen Property Reported ---YesNo
Police Details
Officers Name
Docit No
Stations Tel No

Racing

Were You Under Starters Orders ---YesNo
Type of Race ---ClubOffshoreorMajorRace
Race Name
Approximate Distance
Did You Protest ---YesNo
If yes, Please forward All Documents
What Was The Outcome

Vessel

Name of Repairer
Address of Repairer (line 1)
Address of Repairer (line 2)
Address of Repairer (line 3)
Contact Number of Repairer
Inspection Address of Damaged Vessel (line 1)
Inspection Address of Damaged Vessel (line 2)
Inspection Address of Damaged Vessel (line 3)
Estimate (if obtained)

Witnesses

Witness Name 1
Witness Name 2
Witness Name 3
Witness Number 1
Witness Number 2
Witness Number 3

General

In Respect of the Risks Covered By This Insurance, Has Any Loss, Damage or Liability Arisen, Whether Insured or Not In The Last 10 Years? ---YesNo
If Yes, Please Give Circumstances, Dates and Costs Incurred.
Is There Any Other Insurance on the Property Under This Claim? ---YesNo
If Yes, Please Give Details
Please Supply the Full Details of the Incident