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MARINE HULL CLAIM FORM

PLEASE NOTE: An agent who completes a Proposal Form does so as an agent of the proposer.

It is essential that every question with * be answered fully for proper processing of the form.

POLICY NO.

SECTION ONE

Full Name of Insured *

Private Address *

Business Address

Mobile Tel. No. *

Tel. No.

E-mail Address *

Agent / Brokers

Name of Vessel

Type

Purchase value a) Hull

b) Machinery

Insured value a) Hull

b) Machinery

Whether Purchased New or Second Hand

Make

Date of Purchase

If subject to hire purchase agreement state name of company

SECTION TWO

PARTICULARS OF ACCIDENT / DAMAGE

Date, Time and place of accident

Weather conditions:( Give details of direction and force of wind, tide and extend of visibility)

If Dark period, what navigation lights were displayed?

If laid up ashore/laid up afloat on permanent / temporary moorings, state system of security

Is the Damage to Hull and Machinery total or partial?

If Partial, what damage was caused to the insured vessel?

Where only machinery is damaged or lost, State

MAKE	TYPE	ENGINE NO	YEAR OF MAN

Present location of vessel for purpose of inspection

Repairer's name, address and telephone no

SECTION THREE

PARTICULARS OF THEFT
In the event of theft, state the date,place and time of the theft
When and by whom was the theft discovered?
Was the vessel on commission or moored at the time of theft?
If moored, state the security measures taken
Was the vessel left unattended and if so, for how long
Has any official report been made to the police?
If yes state the name of the police station and the action taken so far
In the circumstance of theft, do you suspect anybody of any foul play?
Give details of the theft and value of items lost

SECTION FOUR

PARTICULARS OF DAMAGE / ACCIDENT TO THIRD PARTIES PERSONS AND/OR PROPERTY
Was there any damage to third party's vessel?
If yes, what is the extent of damage ?
Where is the vessel now lying
Name and address of owner
Has the vessel been sent for repairs?
If yes, give name and address of repairer
Was there any injury to the third party?
If so give details
Has any claim been made against you by the third parties?

SECTION FIVE

Narrate fully the circumstance of the loss/damage/accident
Upload a sketch of the scene of the accident, courses, position and point of impact *
Name and address of witness:	a)
	b)
	c)

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