Claim notification form Claim notification Step 1 of 13 7% Section 1. Information about the clientName* First name Last name Address* Street Adress Adress Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Email* Phone Number*Phone Number (Cellphone)Insurance Policy N°Insurance Policy contract - Please upload the documentAccepted file types: jpg, pdf.Proof of payment of the insurance premium- Please upload the documentAccepted file types: jpg, pdf.Boat license detained Section 2. General informationIn terms covered risk under this insurance, has there been any loss and/or damage suffered or liability involved, insured or not, within the last 10 years?YesNoIf yes, please detail the circumstances, the loss suffered, the date and the costs generatedAre you the owner of the vessel?YesNoAre you the sole owner?YesNoIf no, please indicate the names of the co-ownersIs the vessel leased or chartered?LeasedCharteredPlease indicate the name of the owner or company leasing the vesselIf chartered, please chooseChartered with SkipperChartered without SkipperIs there any other insurance contract covering this vessel and this incident?YesNoPlease specify Section 3. Information about the vesselName of VesselType of vesselManufacturerModelConstruction yearSerial number (HIN/CIN)Registration portRegistration numberLengthWidthDraftSurface area of the sailsKind of motorInboardOutboardNo motorCurrent value of the vessel (approx. in EUR)Current value of the motor & of the propeller (approx. in EUR) Section 4. Information about the circumstancesDeparture port:Use of the vesselPleasureBusinessSkipper or Bareboat Charter?Skipper CharterBareboat CharterNo CharterIntended destination & routesPort nearest to the incidentGeographic coordinates (longitude & latitude) or place of incidentWeather conditionWind: Speed & DirectionVisibilitySea condition:calmmoderateroughstormActivity Moored Repair yard Underway Road transit On tow Racing Anchored Laid up ashore Laid up afloat Exhibition waterskiing or similar activity Berthing / Docking Other Other: please specify Section 5. Type of incidentType of incident Collision Grounding Mechanical damage, damaged equipment Capsize Fire / Explosion Lightning Piracy Theft Sinking Wind damage Water damage Storm damage Malicious damage Other Other: please specifySection 6. Claimed lossClaimed loss Total loss Machinery damage Mast, Spars, Rigging, Sails Trailer Outboard Motor Propeller / Shaft only Rescue costs Hull damage Tender / Dinghy Personal belongings Rudder / Keel Personal accident (i.e. bodily injuries) Third party liability Equipment: please specify Equipment: please specify Section 7. Damaged equipementType of equipment damagedDamage sufferedPurchase date Purchase value (in EUR)Estimation of the repair and/or replacing costs (in EUR)Diminished (depreciated) value (in EUR)Amount claimed (in EUR)Has the equipment been stolen or lost?YesNoSpecify all information that could help identifying it: Section 8.1. Third party liabilityManufacturer & Brand of the other vesselName of the owner of the other vessel First Last Address of the owner of the other vessel Street Adress Adress Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Email of the owner of the other vessel Phone of the owner of the other vesselName of the skipper of the other vessel First Last Address of the skipper of the other vessel Street Adress Adress Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Email of the skipper of the other vessel Phone of the skipper of the other vessel Section 8.2. Third party liabilityWitnesses (if any)Full NameAdressPhone numberEmail Insurers and Policy number of third party involvedAccident statement duly filled?YesNoAccident Statement - Please upload the documentAccepted file types: jpg, pdf.Did you accept liability?YesNoWere you at fault?YesNoPartiallyDescription of the damages suffered by the other vesselEstimation of the value of the damage suffered by the other vessel (in EUR)Bodily injury?YesNoPlease specify Section 9. Information about the incidentDate of incident Time of incident : HH MM Was the vessel seaworthy before departure?YesNoExceptional navigation condition (difficult navigation, strong currents, damage, abrupt movement, injured/sick person, etc.)Exceptional circumstances (buoy light off, sea mark missing, etc.)Did the incident happen during a race?NoYesType of RaceClub RaceOffshore / Major RaceName of the race / regattaApproximative length of the raceWas there a protest?NoYesCopy of the protest and all the declarations - Please upload the document Drop files here or Accepted file types: jpg, pdf. What was the outcome of the protestSpeed of the boat when the incident happenedWere all security rules respected?NoYesMeasures taken to avoid the incidentName of the skipper in charge at the moment of the incident First Last Address of the skipper in charge at the moment of the incident Street Adress Adress Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Email of the skipper in charge at the moment of the incident Phone of the skipper in charge at the moment of the incidentLicense detained by the skipper in charge at the moment of the incidentYears of experience of the skipper in charge at the moment of the incidentWas the skipper under the influence of alcohol, drugs or any medicine?NoYesIf Yes please specifyHow many people were on board including the skipper?Please enter a value greater than or equal to 0.Was the boat inspected by a specialist following the incident?NoYesReport of specialistIs an estimate of the repair cost available? Please include a copy of the estimation documentYesNoCopy of estimation document - Please upload the documentAccepted file types: jpg, pdf.Repair company suggested to repair the damages?Phone of the repair companyEmail of the repair company Where can the boat be inspected?Name of person to reach First Last Phone of person to reachEmail of person to reach Summary of the incident Section 10. Witnesses and/or authorities involvedDid any authorities (coast guard, harbour officer, receiver of wrecks, police and/or any other official) witness the incident or were they contacted ?NoYesIncident N°Contact Person First Last Email of Contact Person Phone of Contact PersonIncident Report - Please upload the documentAccepted file types: jpg, pdf.In case of stolen / lost claim: Was it reported to the police?NoYesPolice Report - Please upload the documentAccepted file types: jpg, pdf. Section 11. After the incidentMeasures taken after the incident (to keep the boat floating, towing, etc.)Name of Towing CompanyDate of Towing Time of Towing : HH MM Details on the safe arrival in port: name of the portDate of safe arrival in port Time of safe arrival in port : HH MM Section 12. Additional InformationAdditional InformationsAdditional Documents - Please upload the document Drop files here or Accepted file types: jpg, pdf. Section 13. Banking detailsAccount holderBank nameAccount numberIBANSwift/BIC* I confirm that the information I provided is true, complete and accurate. I acknowledge the fact that by concealing and/or refusing to provide the information and/or or providing incorrect information, I render the processing of my request more difficult and possibly inaccurate and that, in such case, I will have to reckon with consequences up to federal sanctions. * I confirm that I have read and agree to the privacy policy!
