Marine Cargo Insurance Statement of Facts
Policy Number
Name of Insured
Contact Number
Email
Vessel Name / Carrier
Voyage From
Voyage To
Date of Shipment
Date of Arrival
Container Number(s)
Bill of Lading / AWB No.
Description of Goods
Quantity
Insured Value (Currency & Amount)
Date & Time of Loss/Incident
Location of Loss/Incident
Nature & Extent of Loss/Damage
Cause of Loss (if known)
How and when was loss/damage discovered?
Action Taken Following Loss/Damage
Was a Survey Carried Out? By Whom?
Other Interested Parties (Notify if any)
Reported to Authorities? (Give details)
Date Reported
Additional Remarks
Declarant Name
Position/Title
Date
Signature