boat insurance incident

claim form
BOAT INSURANCE INCIDENT
Policy No.
Insurer: Swann Insurance (Aust) Pty Ltd ABN 80 000 886 680 AFS Licence No. 238292.
YOUR PERSONAL INFORMATION (POLICY HOLDER)
Title
Given name(s)
Surname
Address
Town/Suburb
State
Home Phone
Business Phone
Postcode
Mobile Phone
Email Address
Preferred Written Contact Method (Australia Post, Email)
INSURED BOAT DETAILS
Description of boat involved in the incident
Registration No.
Year of Manufacture
Make/Model/Series
Was a trailer involved in the incident?
No
Yes
Type
Make
Registration No.
Make
Registration No.
Was a motor involved in the incident?
No
Yes
Type
Do you owe money on the boat?
No
Yes
Lender’s Name
Approximate Amount Owing
$
Has the boat been modifed or converted from the manufacturer’s specifcation or ftted with accessories other than those supplied by the
manufacturer?
No
Yes
Describe the modifcations/accessories
Was there any unrepaired damage to the boat before the incident?
No
Yes
Describe the unrepaired damage
Is the boat currently registered?
No
Yes
Expiry date
/
/
What were you using the boat for at the time of the incident? (e.g. pleasure, racing, skiing, road transit, moored)
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Was the boat being used for skiing or aquaplaning?
No
Yes
How many skiers were being towed?
Was there an observer on the boat?
No
Yes
TYPE OF CLAIM
Collision
Theft
Malicious Damage
Storm
Sinking
Transit Damage
Liability
Other – Please specify
PERSON IN CHARGE OF THE BOAT
Who was in charge of the boat when the incident or theft happened?
Relationship to Insured (e.g. son, daughter)
Address
Postcode
Home Phone
Business Phone
Mobile Phone
Did the person in charge of the boat have the knowledge and consent of the insured?
No
Yes
Current Licence No.
Date of Birth
/
/
Did this person drink any alcohol, or take any drugs or medication in the 12 hours prior to the incident?
No
Yes
What did this person drink or what drugs or medication did this person take?
When?
How much?
Have you ever been charged with, or convicted of a maritime ofence or been disqualifed from driving a boat in the past fve years?
No
Yes
State the details
Have you been charged with, or convicted of, any criminal ofence in the last ten years?
No
Yes
Details of prosecutions, penalties, fnes, bond imposed
Have you ever had insurance declined or cancelled, had a renewal refused or had special conditions imposed by an insurer?
No
Yes
State the reasons
INCIDENT DETAILS
When did the incident happen?
Day
Date
Time
/
/
a.m.
p.m.
Where did the incident happen?
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How did the incident happen?
Describe in detail the circumstances leading up to the incident and how the incident happened. It is important to be as accurate as you can.
Please tell us all the facts, even if they are not in your favour. Tell us which person you feel is at fault and why.
Using the symbols below draw a diagram of the incident scene showing the position of all vessels and vehicles (if any). Indicate by arrows the
direction each was travelling, the north point of the compass, and any relevant information such as street names. Please identify any other vessels
or vehicles involved as ‘2’, ‘3’, ’4’ etc. It is important that the sketch be as accurate as possible as it may be used in legal proceedings.
Insured Boat
Other
Vessel
Swimmers
Skiers
Your
vehicle
Other
vehicle
Pedestrian,
Cyclist etc.
Road
Stop
sign
Give way
sign
Lights
2
Please sketch the areas of your boat
damaged in the incident.
Your boat
What was the speed of the boat at the time of the incident?
What is the estimated cost of repairs if relevant? Please attach a quote.
$
If we wish to inspect the boat, who do we contact and where will the boat be?
Name of Person
Telephone No.
Address where the boat is being kept
Postcode
OTHER PARTIES DETAILS
Please provide information about the other parties, even if they were not damaged. This will help our investigation.
Owner’s Details
Full Name
Telephone No.
Address
Postcode
Owner’s Insurance Company
Policy No.
Make, Model, Body Type
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Registration No.
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Year of Manufacture
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Details of person in charge of vessel/vehicle
Full Name
Current Licence No.
Telephone No.
Date of Birth
/
Please sketch the areas of the other vessels/
vehicles damaged in the incident
/
Vessel/Vehicle
(If any other vessels/vehicles were involved, please attach details of those vessels/vehicles not mentioned above on a separate sheet)
As a result of the incident, was there any other property damaged (e.g. buoys, fences, telephone poles)?
No
Yes
Provide details
Name of Property Owner
Telephone No.
Address
Postcode
Was anyone injured as a result of the incident?
No
Yes
the driver
or passenger
Person’s Surname
Given Name(s)
Address
Postcode
Telephone No.
Age
Nature of injuries
If taken to hospital, state the name of the hospital
Have you received a claim from the injured person or the owner of the damaged property?
No
Yes
Attach any correspondence relating to this claim
Were there any witnesses to the incident?
No
Yes
Name of Witness
Address
Postcode
Telephone No.
Type of Witness:
Passenger In – Insured’s Boat
Other Vessel/Vehicle
Independent Eye Witness
Did the police attend the incident?
No
Yes
Ofcer’s Name
Name of Station
Was the incident reported to a police station?
No
Yes
Ofcer’s Name
Name of Station
Date
Police Report No.
/
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Was any driver or person in charge of any vessel/vehicle asked to take a blood/breathalyser test?
No
Yes
Insured Driver/Person
%
The Result
Other Driver/Person
%
The Result
Was any person charged with an ofence or ofences or advised that charges may be laid?
No
Yes
Insured Person
and the ofence(s)
Other Person
and the ofence(s)
PERSONAL INJURY
Please provide details of injured person.
Injured Person’s Details
Full Name
Telephone No.
Address
Postcode
Relationship to Insured (e.g. son, daughter)
Was the bodily injury sustained within 12 months of the incident?
Yes
No
Were you treated at a Medical Facility or Hospital for your injuries?
Yes
No
Name of Medical Facility/Hospital
Address of Medical Facility/Hospital
Name of Doctor
Please describe your injuries from the incident
THEFT DETAILS
What was stolen?
Boat
Accessories
Please list
When was the Boat last seen?
Day
Date
Time
/
/
a.m.
p.m.
Who last saw the Boat?
Full Name
Relationship to Insured (e.g. son, employee)
Address
Home Phone
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Postcode
Business Phone
Mobile Phone
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Who discovered the theft and when?
Full Name
Date
Time
/
/
a.m.
p.m.
Do you know who is responsible for the theft?
Yes
No
State the names and addresses or any other identifying information
To which police station was the theft reported?
Ofcer’s Name
Name of Station
Date Reported
/
Time
/
Police Report No.
a.m.
p.m.
Was the Boat recovered?
No
Yes
Explain the circumstances surrounding the recovery (e.g. who, when, where)
If damaged, provide details
Please sketch the areas of your Boat
damaged in the theft.
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Your Boat
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DECLARATION
1.
I/we declare that to the best of my/our knowledge and belief the particulars in this form are true and correct and I/we have not withheld any
relevant information.
2. I/we undertake to give all assistance in dealing with this matter.
3. I/we authorise Swann Insurance (Aust) Pty Ltd (Swann) to procure any or all relevant information from a relevant regulatory or law
enforcement authority.
4. I/we agree that a signed copy of this declaration/authority may be utilised as if it were the original.
5. I/we consent to Swann using my/our personal information I/we have provided on this form for the purpose of processing this claim. I/we
understand that if I/we choose not to provide the required details, Swann may not be able to process this claim.
6. I/we consent to Swann disclosing my/our personal information to other insurers, an insurance reference service, the fnancier, its service
providers and/or advisors, any third party with whom I/we have been dealing in respect of this insurance and who referred me/us to Swann,
and any other party as permitted or required by law. I/we consent to Swann also disclosing my/our personal information to and/or collecting
additional information about me/us from investigators or legal advisors.
7.
I/we hereby authorise Swann to move the boat to any place of storage or repair and take any other action Swann considers necessary to
implement repair or reinstatement of the boat.
8. I/we agree that, by submitting this form the personal information I/we provide to Swann in this form or otherwise may be collected, held,
used and disclosed in a manner set out in the Swann Privacy Policy found at www.swanninsurance.com.au/privacy, including for processing
this claim.
Signature of the insured or person with authority sign for and on behalf of a company or partnership
Signature of the person in charge of the boat (if not the insured)
Date
/
/
/
/
Date
Please indicate the number of additional pages attached to this claim report:
When complete, please forward the report to:
Email - [email protected]
Post - Swann Insurance (Aust) Pty Ltd, Locked Bag 3275 Melbourne VIC 3001
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