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Policyholder Details

Policy Number:

Full Name:

Occupation:

Day Phone No:

Day Fax No:

Home Phone No:

Home Fax No:

Home Address:

Post Code:

E-mail Address:

Are you registered as a taxable person for VAT?

Was there any other insurance covering this craft at time of loss?

Were you helming or last person in charge of craft prior to loss?

Craft Details

Class:

Builder:

Year Built:

Current Value:

Name:

Sail Number:

Hull Number:

Hull Material:

Spar Material:

Circumstances of Loss-Accident

Date It Occurred

Exactly Where?

Wind Force

If Club or Marina: Name:

What Happened?

Why Did That Happen?

Is Anyone Else To Blame?

If so, Their Name

Their Address

Their Insurer

Why it's Their Fault

Detail Your Loss-Damage

Where Can Damage Be Inspected

Name/Address or Repairer You Would Like To Use

If Theft, Police Station: Name:

Address:

Phone:

Reference:

If other craft damaged by you & your fault please state that owners:

Name:

Address:

Their Insurer:

Any other information you feel will be helpful to insurers please state below:

If you have any specific questions please state them below:

I/We declare that the whole of the statements made on this claim form are true in every respect and I/We agree that if any false or untrue statement or any suppression or concealment of material fact has been made, the right to recover under this policy shall be absolutely forfeited. Date & time as per transmission header, policyholder's conformation of agreement to this declaration by re-confirmation of his/her name below:

Policyholder's Name

CHECK BEFORE SUBMITTING THAT YOU HAVE ANSWERED ALL QUESTIONS.