MARINE CLAIM FORM
YACHTS / DINGHIES & PLEASURE CRAFT
   
INSURED

 
Name of Vessel:    
Name:    
Address: Occupation:
Cell: Telephone No:
Fax No: Email Address:
Id No: Vat No:
   
LOSS/DAMAGE OCCURRENCE
Date of accident:
Time of accident:
Where did accident occur?
Was vessel racing at the time? Yes No
Nature of accident with full
details.

If the vessel was laid up at
the time of accident was she
Afloat ,on a Mud berth or
Hauled out?		 Afloat   On a mud berth   Hauled out
Who was in charge at the
time of accident?:
Names and addresses of
witnesses:
Where may the vessel be
inspected?:
Details of any assistance
rendered and the names
and addresses of persons
rendering it.:
Is there any other Insurance
(If so, give name of Insurer):
   
PAYMENT METHOD
Name of bank:
Branch:
Account Holder:
Branch Code:
Type of account:
Account number:
   
DECLARATION
I/We solemnly declare that the above particulars are true in every respect.
   
Signature: