United Survey Group -

TPA Claims

INSURED
Name:		Address:
E-mail Address:
Telephone No.: Daytime:		Evening:
Mobile #		Facsimile #

POLICY
		Insurer:
Policy No.:		Certificate No:
Period of Insurance: from		to
Sum insured:

CASUALTY
Date:		Location:

PERSON IN COMMAND OF THE VESSEL
Name:		Address:
Zip Code:
Telephone No.: Daytime:		Evening:

OTHER PERSONS ON BOARD THE VESSEL
Name 1:		Name 2:
Name 3:		Name 4:
Address 1:		Address 2:
Address 3:		Address 4:

DETAILS OF CASUALTY
Please provide a full and concise report of how the casualty occurred, this must state CAUSE. In the case of theft, please describe the anti-theft devices and the security arrangements in force and define the means of entry. In the case of Personal Accident/Injury please we will contact you and request that you provide a separate report by the person in command of the vessel and/or at least one one witness to the casualty.
Day:		Date:
Time:
Precise Location:		Sea State:
Weather Conditions:


USE OF VESSEL AT TIME OF CASUALTY:

DAMAGE AND LOSS TO INSURED VESSEL
Nature and extent of Damage/Loss:
Approx. Cost:
Underwriters may require to instruct a surveyor to attend prior to repairs being carried out. Please submit a formal written estimate of cost as soon as possible.
Proposed Repairer:		Address:


FIRST AID REPAIRS
It is the duty of the insured to take such measures as may be reasonable for the purpose of averting or minimising the loss.
What has been done to minimise the loss:
Who has carried out the works:

SALVAGE
If Salvage services have been rendered, please provide full details including names and addresses of those who claim to have rendered such services and under what circumstances

THEFT OR MALICIOUS DAMAGE MUST BE REPORTED PROMPTLY TO THE POLICE
Please confirm
Who advised the local Police:
Date that local Police were advised:
Crime report No.:
Postal Address of Police Station:

Zip Code:
Telephone No. of Police Station:

SHIP’S BOAT/DINGHY
In the case of Loss of or Damage to Ship’s Boat/Dinghy – Please confirm:
Makers Name:		Type:
Length:		Age:
Sum Insured:
That she was permanently marked with the name of the parent vessel: Yes No

OUTBOARD MOTOR
In the case of Loss of or Damage to Outboard Motor – Please confirm:
Makers Name:		Model:
Serial No.:		Age:
Sum Insured:		The Anti-theft device in use:

IF A THIRD PARTY IS INVOLVED
Name:		Address:

		Zip Code:
Telephone No.: Day:		Evening:

THIRD PARTY VESSEL/PROPERTY/PERSON
Nature and extent of Damage/Loss – if known:
Approx Cost:
Proposed Repairer:		Address:


INDEPENDENT WITNESSES
Name 1:		Name 2:
Name 3:		Name 4:
Address 1:		Address 2:
Address 3:		Address 4:

RESPONSIBILITY AND LIABILITY
In your opinion, who was responsible and why:
If casualty occurred whilst racing please provide a copy of the Protest Committee report/findings.
Has any Claim been made against you: Yes No
Note: If a claim is made against you, DO NOT accept responsibility or make any offer of settlement. You should merely acknowledge receipt of any communications received and immediately forward same direct to this office for our attention. If you believe that the Third Party is responsible then you should write to them, with a copy to this office, formally holding them responsible for the casualty and liable for any costs/losses incurred as a result of the casualty.

DECLARATION
I/We declare that the foregoing particulars are true and correct to the best of my/our knowledge and belief, and that I/We have not withheld any material information concerning the claim. I/We agree to provide any information or documentation as may be reasonably required. By submitting this form you are showing acceptance of the above statements.

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