YACHT INSURANCE CLAIM FORM

1. (a) Policy #:

(b) Name of Vessel:

2. (a) Name of Owner:

(b) Address:

Telephone (W):

Telephone (C):

(a) Date of Accident:

(b)

Time of Accident:

(c)

Location of Accident:

4. (a) State of Weather:

(b) Wind:

(a) Please give full details describing how the accident happened. (If further space is required please continue overleaf)

(b)

Was the vessel racing at the time of the accident?

Yes

(a) State the nature and extent of loss or damage. If theft, proceed to question 6 (b).

(b)

Which Police Station was the theft reported to?

(c)

Was an outboard motor involved in the accident?

Yes

If Yes, please provide the following information?

Make:

Model:

Horsepower:

Date of Manufacture:

Serial #:

Please state the approximate cost of repairs.

(An estimate from a firm of repairers should be submitted as soon as it is available)

What is the present location of the vessel?

If any other vessel is considered at fault, give the following details:

Name of Owner:

Address of Owner:

Name of Vessel:

On what grounds is the vessel considered at fault?

(A copy of your letter holding the Owner responsible should be sent with this form)

10.

Give the name and address of the nearest repair yard.

11.

Particulars of Witnesses:

1 Name of Witness

Address

Remarks

2 Name of Witness

Address

Remarks

3 Name of Witness

Address

Remarks

NOTE: It is a requirement of this insurance that this information be supplied to us as soon as possible and before any repairs are commenced, so that we may appoint our own surveyor, if we so desire.

DECLARATION

I/We declare that to the best of my/our knowledge and belief that the particulars and answers given above are true and correct.

YACHT INSURANCE CLAIM FORM

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