Accident Report Form

Please complete the form below and press the submit button, we will then respond as soon as possible. Alternatively please click here and download the form which you can then complete and either post or email to us. Please click contact us for addresses.

SECTION 1: INSURED/OWNER

FULL NAME
ADDRESS 1
ADDRESS 2
TOWN
POSTCODE
COUNTRY
PHONE (DAY)
PHONE (HOME)
PHONE (MOBILE)
FAX
EMAIL(S)
CLAIM NO.
POLICY NO.
ARE YOU THE OWNER?
IF NO - OWNER NAME
VAT REGISTERED?
STATUS AND VAT NO.


SECTION 2: VESSEL DETAILS

NAME OF VESSEL
HULL/CRAFT ID NO.
CLASS OF VESSEL
SMALL SHIPS REG NO.


SECTION 3: SKIPPER/CREW

Who was in charge of the vessel at the time of the incident?
FULL NAME
ADDRESS 1
ADDRESS 2
TOWN
POSTCODE
COUNTRY
PHONE (DAY)
PHONE (HOME)
PHONE (MOBILE)
FAX
EMAIL(S)
NO. YEARS BOATING EXPERIENCE
BOATING QUALIFICATIONS
(if any)
Please state the number of people on board with their names and status e.g. navigator, helmsman, crew;
 


SECTION 4: DETAILS OF THE INCIDENT

DATE & TIME OF INCIDENT
PRECISE LOCATION
SPEED OF VESSEL
DEPTH OF WATER
EBB/FLOOD TIDE
DIRECTION AND SPEED
OF CURRENT
DIRECTION AND SPEED
OF WIND
PLEASE STATE THE PURPOSE FOR WHICH
THE VESSEL WAS BEING USED AT THE
TIME OF THE INCIDENT
WAS THE VESSEL RACING OR
UNDER PREPARATORY SIGNAL AT
THE TIME OF THE INCIDENT?
IF RACING WAS A PROTEST MADE?
IF YES WHO MADE IT AND WHAT
WAS THE OUTCOME?
IN YOUR OPINION WAS
THE CASUALTY DUE TO A FAULT
IN DESIGN/FAULT IN
MANUFACTURE/FAULT IN
MATERIALS/INADEQUATE STRENGTH?
IF YES PLEASE GIVE DETAILS OF THE
SUPPLIER/
BUILDER/MANUFACTURER
HAVE YOU TAKEN UP THE MATTER WITH THEM?
IF YES WHAT RESPONSE HAVE YOU HAD?
WHO IN YOUR OPINION WAS RESPONSIBLE AND WHY? PLEASE GIVE DETAILS AS TO WHAT YOU CONSIDER RELEVANT AND WHY


SECTION 5: MOORING FAILURE

IF THE MOORING WHICH
YOUR VESSEL WAS ON
DRAGGED OR BROKE,
PLEASE
GIVE DETAILS OF ITS
TYPE AND SPECIFICATION,
CONFIRMING WHICH PART FAILED AND WHY
WHEN WAS THIS LAID AND BY WHOM?
WHO IS RESPONSIBLE FOR THE LAYING AND MAINTAINING OF
THE MOORING?
WHEN WAS IT LAST INSPECTED AND BY WHOM?
If you have a mooring contract or invoices for the maintenance please supply copies


SECTION 6: MAST/SPARS/SAILS/RIGGING

If loss or damage has been sustained to your mast/spars/sails/rigging please confirm:-
MAKE/SECTION OF THE MAST/SPARS AND THEIR AGE
MAKE/MATERIAL OF THE SAILS, THEIR AGE AND WHEN THEY WERE LAST VALETED
THE AGE OF THE RIGGING AND WHEN THIS WAS LAST INSPECTED AND BY WHOM
CAUSE OF THE FAILURE/DAMAGE
WHERE CAN THE DAMAGED PARTS BE INSPECTED?


SECTION 7: MACHINERY

If your outboard/inboard or outdrive is involved, please confirm the following:-
MAKE
MODEL
HP
SERIAL NO
YEAR OF MANUFACTURE
CURRENT MARKET VALUE


SECTION 8: TENDER DINGHY

If your tender dinghy has been lost or damaged, please confirm the following:-
MAKE
MODEL
LENGTH
SERIAL NO
YEAR OF MANUFACTURE
CURRENT MARKET VALUE
HOW WAS SHE MARKED WITH THE NAME OF THE PARENT VESSEL OR OTHER IDENTIFYING MARKS?
ANY OTHER DISTINGUISHING FEATURES?


SECTION 9: DAMAGE/REPAIRS

PLEASE GIVE FULL DETAILS OF DAMAGE/LOSS SUSTAINED TO YOUR VESSEL
ARE YOU PREPARED TO CARRY OUT YOUR OWN REPAIRS?
IF YES PLEASE SUPPLY YOUR OWN ESTIMATE
HAVE YOU OBTAINED WRITTEN ESTIMATES? IF SO PLEASE FORWARD ASAP. IF YOU HAVE BEEN GIVEN A VERBAL INDICATION PLEASE GIVE APPROXIMATE FIGURE:
WHERE IS YOUR VESSEL NOW AND IN WHOSE CHARGE?


Full description of property lost, destroyed or damaged with model and serial numbers. Are you the sole owner? Date of manufacture? When purchased? Price paid? Estimated cost for repair or replaced if repair not possible. Deduction for age, use, wear & tear. Sum claimed


SECTION 10: STATEMENT

Please give a full and concise report of the incident (if appropriate please send us a sketch):


SECTION 11: THIRD PARTIES

If a Third Party is involved, please give details below, names, addresses, name(s) of craft and damage sustained to their craft:
HAS ANY CLAIM BEEN MADE AGAINST YOU?
If YES please pass onto us any correspondence you have received. Do not admit liability or make any offer or promise, merely acknowledge any correspondence indicating that the matter is receiving attention.


SECTION 12: SALVAGE

If any salvage services have been rendered, please give full details, including names and addresses of those who claim to have rendered such service and under what circumstances:


SECTION 13: WITNESSES

Please give names and addresses of any person or persons of independent status who witnessed the incident:


SECTION 14: OTHER INSURANCE

Do you have any other insurance policy i.e. Personal Liability, and/or All Risks cover under your Household policy, which may cover you in respect of this incident?
IF YES PLEASE NOTIFY THEM AND GIVE DETAILS


Please enter the security code shown:


By submitting this form I/We hereby declare that the particulars on this form are true. I/We acknowledge that any misleading, false or untrue statement will mean that my/our claim will not be paid.


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