BOAT CLAIM FORM

Issuance of this form is not to be taken as an admission of liability

YOUR DETAILS
Full name:
Your address:
Occupation:
Contact details:

Address:

Telephone
Work:
Home:
Mobile:
Email:
CLAIM DETAILS
Date/time of accident
Please describe location and cause of loss (please give details)
If necessary, continue on a separate sheet and attach.
Who caused loss? Please advise owner's and/or skipper's report on circumstances of loss and/or damage
If yes, has a protest been made? Please advise details.
Please advise weather conditions at the time of the loss and/or damage
If yes please describe
Please advice date mooring was last inspected.
Please give details of damage and/or items lost.
If incident has been reported to Police, please advise date reported/station/police file number.
If yes, please describe:
Other party's name
Other party's address
Type of boat
Name of other party's boat
If insured, by whom
If applicable, please describe details of damage to other boat
Were any witnesses present (including crew, passengers and independent witnesses)? Please list name, address and location of witnesses.
YOUR PRIVACY
We collect and receive your personal information in this claim form to consider your claim. We hold it. You have rights to access it, and correct it under the Privacy Act 1993.
You must provide your relevant personal information to us to comply with the Claims Conditions of this policy. If you fail to do so, we may decline your claim.
We obtain your authority below to transfer your relevant personal information to other members of the insurance industry (including Insurance Claims Register Limited), financially interested parties noted on your policy, and repairers
YOUR PRIVACY
I declare that:
      1 All information given to New India in connection with the claim is true.
      2 No information relevant to the claim has been omitted.
      3 I authorize:
          3.1 New India to disclose this information to:
              3.1.1 Other members of the insurance industry (including Insurance Claims Register Limited), and
              3.1.2 Financially interested parties noted on the policy, and
              3.1.3 Parties repairing or replacing your property.
          3.2 The disclosure of my personal information held by any other parties to New India for the purpose of considering and administering the claim.