Vessel Damage Report & Claim Form

Transcription

1 Vessel Damage Report & Claim Form Sunderland Marine Insurance Company Limited, Salvus House, Aykley Heads, Durham, DH1 5TS, UK Tel: +44 (0) Fax: +44 (0) Website: Established 1882 Registered in England number Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority Sunderland Marine Insurance Company Limited is a subsidiary of The North of England Protecting and Indemnity Association Limited SM 14/DR

2 Vessel Damage Report & Claim Form 1. CLAIMS NAME OF VESSEL NAME AND ADDRESS OF OWNERS TEL. NO NAME AND ADDRESS OF SKIPPER (IF DIFFERENT FROM ABOVE) TEL. NO NATURE OF DAMAGE IN THE EVENT OF MACHINERY FAILURES, MAINTENANCE AND OVERHAUL RECORDS MAY BE REQUIRED CAUSE OF DAMAGE DATE AND TIME PLACE WEATHER CONDITIONS (WIND, SEA, VISIBILITY, ETC.) NAME OF PERSON IN CHARGE NAME OF SURVEYOR INSTRUCTED LOCATION OF VESSEL OR DAMAGED PARTS FOR INSPECTION/SURVEY

3 NAME OF REPAIRER(S) (IF KNOWN) ESTIMATED COST OF REPAIRS (IF KNOWN) ARE PERMANENT REPAIRS TO BE DEFERRED? YES / NO IF SO, UNTIL WHEN? STATEMENT THIS SECTION MUST BE COMPLETED BY ALL CLAIMANTS (THE COMPANY WILL INSTRUCT SOLICITORS TO OBTAIN DETAILED STATEMENTS WHERE REQUIRED). FAILURE TO PROVIDE FULL AND DETAILED INFORMATION MAY CAUSE A DELAY IN HANDLING THIS MATTER CONTINUE ON TO FURTHER SHEETS IF NECESSARY

4 2. TOWAGE / SERVICES PLEASE NOTE - THIS SECTION MAY ALSO BE USED WHEN CLAIMING TOWAGE AGAINST ANOTHER VESSEL NAME OF TOWING VESSEL NAME OF VESSEL TOWED NAME AND ADDRESS OF OWNERS POSITION OF TOWAGE FROM DATE AND TIME REQUEST RECEIVED DATE AND TIME TOWAGE COMPLETED DISTANCE TOWED (AND STEAMED, IF ANY) TO DATE AND TIME TOWAGE COMMENCED DATE AND TIME RESUMED FISHING AMOUNT CLAIMED (IF KNOWN) WEATHER CONDITIONS 3. COLLISION NAME OF THIRD PARTY VESSEL/PROPERTY NAME AND ADDRESS OF OWNERS OF THIRD PARTY VESSEL/PROPERTY HOLDING LIABLE NOTICE SENT? YES / NO DATE AND TIME OF COLLISION POSITION COURSE AND SPEED OF INSURED VESSEL OF THIRD PARTY VESSEL PLEASE ATTACH A SKETCH OR CHART EXTRACT SHOWING POSITION AND COURSE OF VESSELS. DECLARATION IN COMPLETING AND SIGNING THIS DOCUMENT I AM FORMALLY REGISTERING A CLAIM FOR THE ABOVE DAMAGE AND AGREE TO ABIDE BY THE RULES OF THE COMPANY IN ALL MATTERS RELATING TO THIS CLAIM. I HEREBY DECLARE THAT THE PARTICULARS AND ANSWERS GIVEN IN THIS STATEMENT ARE IN EVERY RESPECT TRUE AND CORRECT AND THAT I HAVE NOT WITHHELD ANY INFORMATION WHICH MAY INFLUENCE THE DECISION OF THE COMPANY IN REGARD TO THIS CLAIM. SIGNATURE DATE OWNER/AUTHORISED AGENT.

5 HOW WE USE YOUR DATA BY SIGNING THIS FORM YOU CONSENT TO US PROCESSING ANY PERSONAL DATA YOU DISCLOSE TO US (INCLUDING SENSITIVE PERSONAL DATA) WITHIN THE MEANING OF THE UK DATA PROTECTION ACT WE USE THIS INFORMATION, AND ANY ADDITIONAL INFORMATION WE SUBSEQUENTLY COLLECT FROM YOU IN CONNECTION WITH OUR INSURANCE POLICIES, TO:- i. ASSESS YOUR SUITABILITY FOR AN INSURANCE POLICY; ii. PROVIDE YOU WITH INSURANCE COVER; iii. ISSUE YOU WITH INFORMATION ABOUT YOUR MEMBERSHIP OF SUNDERLAND MARINE, INCLUDING STATUTORY NOTICES, CIRCULARS AND CORPORATE DATA; iv. RENEW OR AMEND YOUR INSURANCE POLICY; v. RESPOND TO ANY CLAIM(S) YOU MAY MAKE; vi. ASSESS FUTURE PROPOSALS FOR INSURANCE; vii. MAKE PAYMENTS IN RESPECT OF CLAIMS UNDER YOUR POLICY ACCEPTED BY US; viii. CONTACT YOU WITH INFORMATION ABOUT OUR COMPANY AND OUR PRODUCTS; AND ix. COMPLY WITH OUR LEGAL OBLIGATIONS. FAILURE TO PROVIDE THIS INFORMATION MAY AFFECT YOUR ABILITY TO ENTER INTO, OR CLAIM UNDER, AN INSURANCE POLICY WITH US. TO ENABLE US TO PAY CLAIMS THAT WE HAVE ACCEPTED, WE MAY NEED TO COLLECT BANK DETAILS FROM YOU. FROM TIME TO TIME WE MAY RETAIN THESE DETAILS SECURELY TO ENABLE US TO PROCESS FUTURE CLAIM PAYMENTS. IF YOU WOULD PREFER US NOT TO RETAIN THIS INFORMATION, PLEASE LET US KNOW. DISCLOSURE OF YOUR PERSONAL INFORMATION BY SIGNING THIS FORM YOU AGREE THAT WE MAY DISCLOSE PERSONAL DATA WE HAVE COLLECTED, OR MAY COLLECT, FROM YOU TO:- i. OTHER (RE)INSURERS; ii. ORGANISATIONS WITHIN THE SUNDERLAND MARINE GROUP (INCLUDING GROUP ENTITIES OUTSIDE THE UK IN COMPLIANCE WITH ALL APPLICABLE DATA PROTECTION LEGISLATION); iii. SURVEYORS, LOSS ADJUSTERS AND OTHER INVESTIGATORS; iv. PROFESSIONAL ADVISORS; v. FINANCIAL AND/OR REGULATORY INSTITUTIONS; vi. ORGANISATIONS THAT PROVIDE SERVICES TO US IN RELATION TO OUR PRODUCTS; AND vii. LAW ENFORCEMENT AGENCIES. THIRD PARTY INFORMATION BY SIGNING THIS FORM YOU CONFIRM THAT YOU HAVE OBTAINED ALL RELEVANT CONSENTS FROM ALL INDIVIDUALS WHOSE DATA YOU DISCLOSE IN THIS FORM (INCLUDING BUT NOT LIMITED TO CREW, SKIPPERS, EMPLOYEES AND OWNERS). IF YOU REQUIRE ANY FURTHER INFORMATION ABOUT OUR DATA PROTECTION POLICY PLEASE CONTACT OUR COMPANY SECRETARY (+44(0) ;