Marine Insurance Claim Form
Insured Details
Name of Insured
Policy Number
Contact Number
Email Address
Address
Vessel / Conveyance Information
Name of Vessel / Carrier
Voyage Number
Port of Loading
Port of Discharge
Date of Departure
Date of Arrival
Consignment Details
Description of Goods
Quantity
Weight
Invoice Number
Invoice Value
Packaging
Claim Details
Date of Loss
Time of Loss
Place of Loss
Nature and Cause of Loss or Damage
Estimated Amount of Loss
Other Information
Has a notice of claim been served on carrier or party?
Yes
No
If yes, to whom and when?
Other Relevant Details
Declaration
I / We declare the above statements are true and complete to the best of my / our knowledge
Signature of Insured
Date