Download accident claim form in PDF Insured party details Name * Surname * Phone * E-mail * Policy Nº Details of loss Date of loss Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year20112012201320142015 Time of loss hour123456789101112 : minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 am pm Place of loss Brief description of loss Damages suffered (material and personal). Details of the parts damaged. Details of third parties involvedComplete only if third party/ies involved in the claim Name Surname Phone Fax Insurance company Policy Nº Damages suffered (material and personal). Details of the parts damaged. Other Information of interest Intervention of any authorities Yes 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 attached1. 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
