Online Claim Form

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This Incident/Claim Form is used for Hull damage claims, Protection & Indemnity liability claims, and incidents that involve or implicate both types of claims. For example, if your vessel collides with another vessel, you may sustain physical damage to your vessel that triggers coverage under your Hull Policy – but crew persons onboard your vessel and/or the other vessel may suffer bodily injuries that prompts coverage under your P&I Policy. Therefore, it is imperative in the case of a Hull collision (or allision, a word often used to describe striking a fixed object such as a pier) that you give serious consideration about potential injury claims and take the time to describe those as well. If the information requested is not applicable, simply write “Not Applicable” or “N/A” in the space provided.

PART ONE – INFORMATION ABOUT YOU AND YOUR VESSEL

Vessel Name(Required)

Official No.(Required)

Vessel Owner Name(Required)

Vessel Owner Email(Required)

Vessel Owner Telephone No.(Required)

Vessel Owner Address

Street Address Address Line 2 City State ZIP Code

PART FOUR – INFORMATION ABOUT THE PEOPLE ONBOARD OR IN SERVICE OF YOUR VESSEL AT THE TIME OF THE INCIDENT

Information About Master/Captain (if different than owner)

Name of Master/Captain

Master/Captain Telephone No.

Master/Captain Email

Master/Captain Address

Street Address Address Line 2 City State ZIP Code

Information About Crew Onboard

Crew Member 1 Name

Crew Member 1 Telephone No.

Crew Member 1 Email

Crew Member 1 Address

Street Address Address Line 2 City State ZIP Code

Crew Member 1 Duties and Title

Crew Member 2 Name

Crew Member 2 Telephone No.

Crew Member 2 Email

Crew Member 2 Address

Street Address Address Line 2 City State ZIP Code

Crew Member 2 Duties and Title

If more than two crew persons onboard at time of incident, please list them in the notes at the end of this form.

PART FIVE – INFORMATION ABOUT OTHER PEOPLE (MEANING THOSE NOT LISTED IN PART THREE) WHO MAY HAVE WITNESSED OR BEEN INVOVLED IN THE INCIDENT

Person 1 Name

Person 1 Telephone No.

Person 1 Email

Person 1 Address

Street Address Address Line 2 City State ZIP Code

Person 2 Name

Person 2 Telephone No.

Person 2 Email

Person 2 Address

Street Address Address Line 2 City State ZIP Code

If more than two other witnesses or people involved in the incident, please list them in the notes at the end of this form.

PART SEVEN – OTHER IMPORTANT INFORMATION ABOUT THE CLAIMS PROCESS

If the incident involves any physical evidence – for example, a tool or equipment that may have injured a crew person – please make sure you tell us where that physical evidence is located and who is in possession of it.
If you filled out and submitted any government forms – for example, USCG 2692, Report of Marine Casualty – or provided any statements to government authorities, please make sure you attach copies to this Incident/Claim Form or provide us with copies as soon as possible.
If you received any communication from an attorney or were served with a summons or other legal papers, please make sure you attach copies to this Incident/Claim Form or provide us with copies as soon as possible.
Please make sure you preserve any documents – for example, voyage logs, settlement sheets, photographs, etc. – that may be relevant to the incident and provide us with the originals or copies as soon as possible.
If you receive any medical bills or reports concerning any alleged injury involving your vessel, or requests for “Maintenance” or “Cure” from any crew person who claims to have been injured onboard or in service of your vessel, please make sure you attach copies to this Incident/Claim Form or provide us with copies as soon as possible.

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Online Claim Form

PART ONE – INFORMATION ABOUT YOU AND YOUR VESSEL

PART TWO – INFORMATION ABOUT ANY OTHER VESSEL(S) INVOLVED IN THE INCIDENT

PART THREE – INFORMATION ABOUT THE INCIDENT

PART FOUR – INFORMATION ABOUT THE PEOPLE ONBOARD OR IN SERVICE OF YOUR VESSEL AT THE TIME OF THE INCIDENT

PART FIVE – INFORMATION ABOUT OTHER PEOPLE (MEANING THOSE NOT LISTED IN PART THREE) WHO MAY HAVE WITNESSED OR BEEN INVOVLED IN THE INCIDENT

PART SIX – OTHER RELEVANT INFORMATION ABOUT THE INCIDENT

PART SEVEN – OTHER IMPORTANT INFORMATION ABOUT THE CLAIMS PROCESS