Claim Form for Boat Insurance, YACHTLINK International

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One moment it's plain sailing ...
... next you might need to use this

Claim Form

Please read Making a Claim carefully before filling in the form below.

Please provide as much detail as possible when filling in the form

Details of the Assured:

Name of Vessel:

Policy No.:

Assured's Name:

Address:

Town/City:

Post/Zip Code:

Country:

Telephone:

Fax:

Mobile Tel.:

E-mail:

Details of the Incident

Place:

Date & Time:

Windspeed:

Wind Direction:

Sea Condition:

Vessel Speed:

Name of Person in control of the Vessel at time of incident/loss:

No. of Years of
Boating Experience:

Qualifications:

Vessel use:

No. of persons (incl.
skipper) on board at time
of incident/loss:

Cause & Activity:

Cause of incident/loss:

If 'Others', please specify below

Activity at time of incident/loss:

If 'Others', please specify below

Declared Loss:

Total/constructive loss	Outboard Motor	Salvage	Tender/Dinghy
Keeel/Rudder	Machinery damage	Trailer	Hull damage
Mast, spars, rigging, sails	Propeller/outdrive only	Equipment	Personal effects
Third party liability	Corporal Damage	Others - please specify below

Third party liability:

Corporal damage details:

Damage details to 3rd party vessel:

Did you recognize responsibility? Yes No Please give details below

Where you liable? Yes No Please give details below

Deatils of Third Party:

Equipment:

If your claim concerns the outboard motor, tender/dinghy, personal effects or equipment,
please give following details below:
  a) Date of purchase and price of purchase
  b) Estimated cost for replacement or repair
  c) Net sum declared for each item
  d) If the tender is lost or stolen, indicate all identifiable elements

Persons advised:

Were the Coast Guard, Port officials, Wreck receivers, Police and/or any
other official Person witness to the incident, take details or make a report?

Yes No
Please give details below

Person to Contact:

Telephone:

Police:

If items were lost/stolen, was the Police informed ? Yes No Please give details below

Date:

Time:

Police Station:

Report No.:

Racing:

Did the loss/damage take place whilst racing (incl. under starter's orders)? Yes No

If so, was it a

Club Race Offshore or major regatta

Name of the Race:

Approximate disstance of the race:

Was a complaint filed? Yes No

What was the result?

You must give full details of the complaint and all relating declarations:

The Vessel:

Location at which the vessel may be inspected:

Contact Name:

Telephone at vessel's location:

Fax at location of vessel:

E-mail at vessel's location:

Have estimates for repair been optained? Yes No

How much is the estimate for the repair:

A copy of the estimate must be supplied.

Name of the Repairer:

E-mail of the Repairer:

Telephon No:

Fax of the Repairer:

Address of the Repairer:

Witnesses:
Names & telephone numbers of all crew members, passengers
and any other persons witnessing the incident:

General:

In respect of the risks covered by this policy, have there been any other loss,
damage or liability, insured or not, in the last 5 years?

Yes No

If yes, give details, dates and costs:

Is there another insurance policy affected by this claim?

Yes No

If yes, give details here:

Complete Deatils of the Incident/Loss:
Please furnish a detailed report of the circumstances of the loss/incident

Declaration:

By sending this form you agree without reservations nor exceptions with the following statement:

I/We declare that the answers and information above are, to the best of my knowledge and belief, true
and just in every respect. I/We have witheld no material information relative to this claim.

Full Name and/or Name of Company:

Position: Date:

You will soon see an acknowledgement that your claim form has been received.
You will recive a copy of this completed form by e-mail.