Carriers / freight forwarders liability claim | Clarity Insurance Brokers

Marine Carriers and Freight Forwarders

WARNING: If you supply any untrue or false information and know that it is not true, your insurer shall have the right to refuse the claim. Please answer all questions on this form. If a question does not apply to your claim, please answer "N/ A"

Under no circumstances should liability be admitted or any offer of settlement be made without your insurer's prior written approval Do not include any comment which could be construed as an admission of liability.

Your insurer has the right to appoint a lawyer or other expert to act on your behalf.

Beneficiary bank account for claim settlement

Account name

Suffix

Bank

Account number

Branch

Details of insured

First Name

Last Name

Policy number

Mobile

Work Phone

Address

Address Line 1

City

State

Details of goods

Name of consignor

Description of Goods being carried

Address of consignor

Address Line 1

City

State

Country

Number of units/packages/articles/animals carried

Name of carrier who loaded the goods into the vehicle

Clean receipt given at time of loading

Yes

Clean receipt given at time of delivery

Yes

Name of any Subcontractors involved in the carriage

Please list any special instructions in relation to the carriage

Details of claim

Date/Time of Loss

Please describe how the loss/damage occurred

Location where loss/damage first discovered

Date you were notified about the loss/damage

Attach Proforma claim/Initial Notice of Loss

Address of where the goods can be inspected

Address Line 1

City

State

Contact Name

Phone

If you feel another person was responsible for the damage to the goods being claimed, please provide any contact details you have for them

Was the cargo damaged as a result of a motor vehicle accident?

Yes

If yes, please provide us with the vehicle insurer and/or claim no.

Amount of claim

Value of Goods lost or damaged

Less policy excess

Less salvage (if any)

Net amount of claim

Documentation required

For your claim to be considered, please include the following documentation where applicable

Consignment Note

Valued claim against you

Copy of any salvage receipts

Signed delivery receipt

Copy of invoice/proof of value

Any other documentation to assist

Pro forma claim against you

Copy of Police Acknowledgement

Declaration and Signature

I /We declare that

Material Facts:

All information given to Clarity Insurance Brokers in connection with this claim (whether written or oral) is true and correct;

No information relevant to this claim is omitted;

Use of Information:

My/ our personal information collected by Clarity Insurance Brokers in connection with this claim may be disclosed to other members of the insurance industry and Insurance Claims Register Ltd;

My/ our personal information held by any other parties in connection with this claim may be disclosed to Clarity Insurance Brokers

Details of my/ our claims made under policies with other members of the insurance industry may be disclosed to Clarity Insurance Brokers

Please Note:

Your insurer will gather information about you (including your claims history) to consider your claim. The terms of your insurance policy require you to supply this information, and if you refuse to provide it, they may decline your claims.

This information is held by us and you may access.

Your claims history is passed onto, and held by, Insurance Claims Register Ltd. This enables other insurers you deal with to access, and prevents fraudulent claims.

Signature of Claimant

Sign Here

Date

Print Name

Position

Claims

Carriers and/or freight forwarders liability claim form

Beneficiary bank account for claim settlement

Details of insured

Details of goods

Details of claim

Amount of claim

Documentation required

Declaration and Signature

24/7 Dedicated Claims Support

Talk to our claims handler