Marine Cargo Claim

Cargo Claim Form

Claimant Details

First

Last

Company Name

Policy / Certificate number

Mobile

Work Phone

Description of goods

Terms of Sale

Other

Address of goods

Address Line 1

City

State

Description of damage

Claim amount

Cause of loss

Attach valued claim

Describe condition of packaging

Dates

Unloaded from vessel / aircraft

Received by Consignee on

Damage / Loss discovered on

Reported to Insurer by

Date

Transit Details

From

Name of vessel

Shipping Company

Airline

Carrier / Other

Customs / Clearing Agent

Voyage number

Container number

Flight number

Freight Forwarder

Devanning Station

General

Was the damage / loss noted at the time of delivery?

Yes

If no, why not?

If yes, was this noted on delivery documentation?

Yes

Has the shipping company / carrier surveyed the damage?

Yes

Has a claim been lodged against the shipping company / carrier?

Yes

Pursuant to the Privacy Act 2020 the following is brought to your attention

• This claim form collects person information about you;
• The information is collected to evaluate your claim;
• The intended recipient of the information is Clarity Insurance Broker and you rinsurer
• The information is collected and held by Clarity Insurance Brokers
• The collection of this information is required pursuant to your insurance policy;
• The failure to provide this information may result in your claim being declined by your insurer;
• You have the rights of access to and correction of this information, subject to the provisions of the Privacy Act 2020.

Declaration

I/We declare that the answers given above and overleaf are true and correct and I/we have not withheld any information or details of previous claims or any other material fact likely to affect acceptance of this claim.

Signature of Claimant

Sign Here

Date

Print Name

Position

Claims