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barksupport
2020-06-09T11:53:29+10:00
The issue of this form does not constitute an admission of liability on the part of the insurer.
Are you registered for GST purposes?
*
Yes
No
Have you claimed an input tax credit on the GST amount applicable to this policy?
*
Yes
No
Specify the percentage amount claimed
*
What is your Australian Business Number (ABN)?
Insured
Full Name
Email
Street Address
Suburb/City
State
Postcode
Work Phone
Work Fax
Mobile
Home Phone
Email
Policy Details
Policy Number
Expiry Date
MM slash DD slash YYYY
Vessel Name
Registration
Accident Details
Location
Date
MM slash DD slash YYYY
Time
Weather Conditions
Sea Conditions
For what purpose was the vessel being used at the time of the accident? (Tick where applicable)
Hire
Racing
Business
Road Transit
Pleasure
Waterborne Accidents
Speed of vessel at time of accident (power vessels only)
Were skiers being towed?
Yes
No
How many
Explain fully how accident occurred
Sketch may be attached
Max. file size: 2 MB.
Helmsman/Driver (Person in charge at time of accident)
Full Name
Age
Street Address
Suburb/City
State
Postcode
Work Phone
Work Fax
Mobile
Home Phone
Email
Relationship to Assured (if applicable)
Boating Licence
Class
How long has the licence been held?
Has the licence ever been endorsed or suspended, or the Helmsman/Driver convicted of any Maritime offence?
Yes
No
Please give details.
Details of Loss or Damage (a quotation for repair will be required)
Estimate of Loss
Where can the vessel be inspected?
Contact Name
Phone Number
In your opinion was the accident your Helmsman’s/Driver’s fault?
Yes
No
(a) Why
(b) Have any claims been made on you?
(a) Who was to blame
(b) Did such person admit any liability?
Names of any independent witnesses
Full Name of Witness
Address
Phone
Police Report
Was the incident reported to the Police or Maritime Authorities?
Yes
No
Did you sign a statement?
Yes
No
Officer’s Name
Number
Stationed At
Has any action been taken or threatened?
Yes
No
Against whom?
CAPTCHA
