Marine Hull claim

Marine Hull Claim Form

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 have 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

Postal Address

Address Line 1

City

State

Details of applicant

Name of insured

Occupation

Address

Address Line 1

Address Line 2

City

State

Mobile

Work Phone

Name of insured craft

Date and time of accident

Place

Type of craft

Details of accident

Conditions at time of accident

Please specify

Was the accident caused by mooring failure?

Yes

If answer ‘Yes’, please state

Is your claim for the theft of an unattended trailered craft?

Yes

If answer ‘Yes’, please state

Was an anti-theft device being used?

Yes

If answer ‘Yes’, please state the type of anti-theft device being used

Does your craft require to be under survey?

Yes

Date of last survey

Surveyed by

If answer ‘Yes’, please state

Is your craft registered?

Yes

If answer ‘Yes’, please state

Registered No

Registered with

Person in command

Name of person in command:

Relationship to the insured (e.g. brother, friend)

Intoxicating substances

Had the helms person or driver of the towing vehicle consumed any intoxicating substance or drug within 12 hours of the accident?

Yes

If answer ‘Yes’, what substance and what quantity?

Over what period?

Damage to craft

Give details of damage to craft (if necessary, continue overleaf or on a separate sheet)

Where can the craft be inspected?

What action, if any, has been taken to minimise the loss, damage or liability?

Estimate for claim

Has an estimate for the claim been obtained?

Yes

If answer ‘Yes’, please state

From whom

Phone

Amount $

Was the craft on its usual moorings?

Yes

When was the mooring last raised?

By whom

Owner of property

Do you own all the damaged or lost property?

Yes

If ‘No’, please state

Name of owner

Their address

Fault

Do you consider the accident to be the fault of any other person?

Yes

If ‘Yes’, please state

Name

Phone

Address

Address Line 1

City

State

Why you consider them to be at fault

Did they admit liability?

Yes

Details of damage to other property

Did anyone get hurt in the accident?

Yes

If ‘Yes’, can you please advise who and their relationship to the driver and known extent of the injuries

Have the police laid or mentioned laying charges against the driver of your vessel?

Yes

If ‘Yes’, do you know what the charges are likely to be?

Racing

Were you racing at the time of the accident?

Yes

If ‘Yes’, please state

Was a protest lodged?

Yes

If ‘Yes’, please state the outcome

Witnesses

Were there any witnesses to the accident?

Yes

First

Last

Address

Phone

Other claims

Have you made any other insurance claims within the past 5 years?

Yes

If ‘Yes’, please state

Insurance company and branch

Property involved and cause of loss

Amount $

Other insurance cover

Do you have any other insurance which covers all or part of your claim?

Yes

If ‘Yes’, please state

Insurance company and branch

Property insured

Amount $

Sketch plan of accident

Upload sketch

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

Title / Position

Claims

Beneficiary bank account for claim settlement

Details of applicant

Conditions at time of accident

Person in command

Intoxicating substances

Damage to craft

Estimate for claim

Owner of property

Fault

Racing

Witnesses

Other claims

Other insurance cover

Sketch plan of accident

Declaration and Signature

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