Ship Crew Medical Insurance Claim Form
1. Crew Member Details
Full Name
Date of Birth
Gender
Male
Female
Other
Nationality
Passport / Seaman's Book No.
Rank/Position
Contact Number
Email
2. Vessel & Employer Details
Vessel Name
IMO Number
Flag
Ship Owner / Employer Name
Employer Contact Details
3. Medical Details
Date of Illness / Injury
Place of Incident
Type of Illness/Injury
Description of Illness / Injury
Date First Consulted Doctor
Hospital/Clinic Name
Doctor's Name
Treatment Given
4. Claim Details
Amount Claimed
Details of Expenses (Medical, Hospital, Others)
Bank Details for Reimbursement (Account Name, Bank, IBAN/SWIFT, etc.)
5. Declaration
I declare that the above information is true and complete to the best of my knowledge.
Name of Claimant
Signature
Date