Claim form

INSURED PARTY DETAILS
Name*
Surname *
Phone *
e-mail *
Policy Nº *
DETAILS OF LOSS
Date of loss
Time of loss
Place of loss
Brief description of loss
Damages suffered (material and personal). Details of the parts damaged.
DETAILS OF THIRD PARTIES INVOLVED
Complete only if third party/ies involved in the claim
Name
Surname
Phone
Fax
Insurance company
Nº de Póliza
Daños propios sufridos (materiales y personales) detalle de las partes dañadas
Details of the place where the damages occurred
OTHER INFORMATION OF INTEREST
Intervention of any authorities
Yesi No
Which?
Place where material damages suffered by the insured vessel will be repaired (details: name of workshop, contact person, workshop tel. place or port)
DOCUMENTATION ATTACHED
1. Copy of seaworthiness certificate for the vessel.
2. Copy of qualification of the person skippering the boat at the time of the loss.
3. Copy of the latest technical inspection of the boat (ITB) Only if applicable.
Attach files
Comments
Send this document by post or fax. We remind you that may also visit our website www.brokmar.com to carry out this procedure online. Thank you for placing your confidence in us.