Home » VESSEL DAMAGE REPORT & CLAIM FORM
THIS SECTION MUST BE COMPLETED FOR ALL INCIDENTS
PROVIDE WRITTEN DESCRIPTION OF THE EVENTS LEADING UP TO AND DURING THE CASUALTY INCIDENT
(THE COMPANY MAY INSTRUCT AN ADJUSTER AND/OR ATTORNEY TO OBTAIN DETAILED STATEMENTS WHERE REQUIRED)
Drag and Drop (or) Choose Files
IN COMPLETING AND SIGNING THIS DOCUMENT I AM FORMALLY REGISTERING A CLAIM FOR THE ABOVE INCIDENT AND AGREE TO ABIDE BY THE TERMS AND CONDITIONS OF THE POLICY IN ALL MATTERS RELATING TO THIS CLAIM
I HEREBY DECLARE THAT THE PARTICULARS AND ANSWERS GIVEN IN THIS STATEMENT ARE IN EVERY RESPECT TRUE AND CORRECT AND THAT I HAVE NOT WITHHELD ANY INFORMATION WHICH MAY INFLUENCE THE DECISION OF THE COMPANY IN REGARD TO THIS INCIDENT
