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Public Liability Claim
Make a Claim
The issue of this form does not constitute an admission of liability on the part of the insurer.
Are you registered for GST purposes?
Have you claimed an input tax credit on the GST amount applicable to this policy?
Specify the percentage amount claimed
What is your Australian Business Number (ABN)?
For what purpose was the vessel being used at the time of the accident? (Tick where applicable)
Speed of vessel at time of accident (power vessels only)
Were skiers being towed?
Explain fully how accident occurred
Sketch may be attached
Helmsman/Driver (Person in charge at time of accident)
Relationship to Assured (if applicable)
How long has the licence been held?
Has the licence ever been endorsed or suspended, or the Helmsman/Driver convicted of any Maritime offence?
Please give details.
Details of Loss or Damage (a quotation for repair will be required)
Estimate of Loss
Where can the vessel be inspected?
In your opinion was the accident your Helmsman’s/Driver’s fault?
(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
Was the incident reported to the Police or Maritime Authorities?
Did you sign a statement?
Has any action been taken or threatened?