Marine Liability Insurance Claim Form

Name of Insured Policy Number Email

Name of Vessel Type of Vessel

Location of Incident Description of Incident Cause of Incident (if known)

Details of Loss/Damage/Injury Estimated Amount Claimed

Name(s) of Third Party Involved Details (contact, address, vessel/vehicle, etc.)

Police or Authorities Notified Witness(es) Name & Contact Other Relevant Information

I declare that the above statements are true and correct to the best of my knowledge and belief.