Yacht Hull Claim Form /0414

Transcription

1 -1 / 5- Instructions in case of an insured event 1. Please describe the course of events leading up to the occurrence of the damage and attach preliminary repair estimates and photos of the damage. Where damage is caused by collision, we additionally require a detailed sketch of the course of events. 2. Please note that you may assign your claims against the insurers to third parties without the insurers prior consent. For larger claims, you may request part payments from us. 3. In the event that the incident is reported to the police ( 11,1 PYHC [Pantaenius Yacht Hull Clauses]), a complete list of the stolen goods, including each individual distinguishing mark and serial number, must be handed over to the police without delay. Please forward a copy of the police report to us. 4. Please note that you may only make the necessary arrangements for repair once you have given the insurer sufficient opportunity to inspect the damages. 5. Additional instructions may moreover be given in the actual individual case. Policy Holder/Vessel: Name/Company: Address: Phone: Fax: Mobile No.: Policy No.: Customer No.: Are you able to recover VAT with regard to this claim? Yes No Name of the Yacht: Model: Build or CIN No.: Year of construction: continue page 2

2 -2 / 5- Short description concerning the damage event: Collision with: Grounding Stranding Fire/Explosion Lightning Mast Breakage Capsizing Sinking Transport Claim Theft Other: Place and Country of Damage: Latitude: Longitude: N/S W/E Date of Damage: Local Time: Weather: Wind Force and Direction: State of the Sea: Visibility: Skipper at the time of the claim event: Address/ /Phone: Licence(s) (Type/No.): Number of Crew-Members: Was the vessel chartered at the time of the claim event? Yes, Bareboat-Charter Yes, Skipper-Charter No, Private Use What measures have you taken, or will you take, to minimize the damage? continue page 3

3 -3 / 5- Please use the space below, or a separate sheet, to describe in detail the incident. Also provide us with a sketch of the damages occurred to the vessel. If the policy holder was not operating the vessel at the time of the incident, the detailed description should be provided by the responsible person for the vessel at that time. Take note of 11 of Pantaenius Yacht Hull Clauses (PYHC) concerning obligations of the insured case of an insured claim event and the consequences of the nonrespect of those obligations. Short Description Concerning the Repairs: Estimated Repair Costs: Important Please provide an estimate; no repairs are to be undertaken without our approval. The insurers must be able to verify the nature, extent, causes and costs of damages except when they specifically renounce this prerogative. What company you suggest should do the repairs? Type of damage on insured vessel: Where can a surveyor inspect the vessel? continue page 4

4 -4 / 5- Did an Authority produce a report? Yes No If yes, please include the report. Is your vessel free from rights of third parties? Yes No If your answer to the above question is no, who has rights on the vessel? Description concerning the Third Party involved in the accident: (Please complete only if another vessel/third Party was involved in the accident) Model and name of the vessel: Owner (Name/Address/Phone/ ): Skipper if different from owner - (Name/Address/Phone/ ): Witnesses (Name/Address/Phone/ ): Please provide their signed declaration and copy of their identity card. Describe damage to the other vessel: Which company insures the Third Party vessel? continue page 5

5 -5 / 5- Please provide name of Insurance Company/Phone/Address/ /Policy No.: Did you make a joint report? Yes No If Yes, please provide a copy of the report. Mandatory Documents for the Handling of Your Claim Please provide us with copies of: - Ownership s Act (Registration documents or equivalent document depending on flag). - Valid nautical license of the person driving the vessel at the time of the accident. - ID of the Owner and the Insured. For a company please also provide for the settlement, all documents should not be older than three months: - A trade register certificate mentioning the name of the person entitled to sign the Subrogation Act. - ID Card of this person. - An original document, certified by a notary or a lawyer, that the signatory is entitled to sign the Subrogation Act for settlements exceeding N.B: Settlement in favor of companies will be net of taxes, unless formal proof, such as an official statement from a CPA, is given that the company is not able to recover VAT in this claim. I agree when submitting the claim to Pantaenius, that my personal data will be saved and made available to insurers, surveyors, law firms and other authorities etc. in so far Pantaenius deems this necessary in order to handle the claim. After closure of the claim, my data will be saved according to the data protection law currently in force. Please note that whenever an insured event occurs, you must provide complete and true information. The insurers would point to the fact that in case of a breach of the existing obligation to provide information or explanations, there is a risk that they would be released from the obligation to provide benefits. Should a third party be entitled to the benefits payable under the contract, the said third party is equally obliged to provide information and explanations. I hereby attest to the accuracy of the afore mentioned declaration Date/Place: Policy Holder s Signature: Skipper: