Tanker Vessel Pollution Claim Form
1. Claimant Details
Full Name
Organization
Address
Phone Number
Email
2. Incident Information
Date of Incident
Location
Reported To (Authority/Agency)
Description of Incident
3. Vessel Information
Vessel Name
IMO Number
Flag State
Owner/Operator
Insurer (if known)
4. Nature of Pollution
Type of Pollutant
Estimated Quantity (tons/liters)
Source (e.g., Tank, Pipe, etc.)
Extent/Area Affected
5. Loss and Damages
Description of Loss/Damage
Estimated Cost (if available)
6. Supporting Documents
List of Attached Documents
7. Declaration
Declaration
Signature
Date