CLAIM FORM: SMALL CRAFT | PLEASURE CRAFT | HULL

ANSWERSQUESTIONS

Policy Number

THE ISSUE OF THIS FORM BY THE COMPANY IS NOT AN ADMISSION OF LIABILITY

Name of Insured

Identity Number

Identity Number

Occupation

Occupation

Tel. No.

Tel. No.

Email address

Give full details of convictions or offences inconnection with handling a craft, if any

Name and Surname of Person in Chargeat the time of accident / loss

Was he / she in the employment of the Insuredat the time of the accident / loss?

If YES, for how long?

Has any Insurer ever refused him / herinsurance or imposed special conditions?

Was he / she sober at the time of theaccident / loss?

Does he / she suffer from any physicaldisabilities?

Type / Class Number of crew

No. of passengers

Motor/s serial and / or identification No.

Hull serial and / or identification No.

Name of Craft / Vessel Lost / Damaged

Lost or damaged Vessel | Articles | Items or Equipment

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Description of Articles / Equipment Lost or damaged

Trailer or Launching trolley description of articles / Equipment Lost or damaged

Address

Address

A

B

C

Manufacture Year Designed speed Horsepower Paintwork (eg glitter) Replacement Value Market Value Sum Insured

Manufacture Year Description of trailer / trolley Registration number Replacement Value Market Value Sum Insured

Replacement Value Market Value Sum InsuredDescription of

specified articles /equipment

Details of Original Purchase

Date when Dealer Where

YES NO

YES NO

YES NO

YES NO

Home:| Work:| Cell:|

Home:| Work:| Cell:|

PO Box 5855, TygerValley 7536Tel:Fax:email:

0861 242 123 086 520 0920

claims@aib.co.za

Associated Insurance Brokers Cape 2006 (Pty) LtdReg No 2005/026692/07 Licensed financial services provider (No 31032)

ANSWERSQUESTIONS

Date of accident / occurrence Time:

Date and Time

Case No.

Case No.

Place

Visibility:Weather: ( wet / fine )

If accident took place at night, were lights exhibited by the insured’s vessel?

were lights exhibited by the other vessel?

If YES, name the signal types given, (visual / audible / other)

Was any signal given prior to the accident / occurrence?

Was the accident reported to the Police?

Was the theft reported to the Police?

By whom?

If YES, By whom?

Was any statement as to fault made by the person in charge of the vessel?

If the vessel remains sunk or stranded,give position as accurately as possible

If YES to other person, please provide the name of that person

State the exact purpose for which the vesselwas being used at the time of the accident

by any other person?

Can the vessel be recovered?

In case of theft, state how, when and by whom the loss was discovered

What precautions were taken to safeguardthe vessel / property

Give full description of circumstances surrounding the loss, damage, accident or theft

Details of the accident / Occurrence

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Who in your opinion was to blame?

Which Police station?

Which Police station?

Are they insured?

Give name, addresses and phone numbers

If any salvage services have been rendered, please give full details of the circumstances including the names and addresses of the persons concerned

Name & addresses Description of their property

Passengers in the insured vessel Independent witnesses

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

SMALL CRAFT | PLEASURE CRAFT | HULL CLAIM FORMPAGE 2

SMALL CRAFT | PLEASURE CRAFT | HULL CLAIM FORM

ANSWERSQUESTIONS

Describe damage to vessel / property / equipment and / or trailer / trolley lost / damaged

Address where vessel / property may be seen

Do you have any other insurance coveringthe same property / event?

Hire Purchase amount owing

to whom

If YES, By whom?

If YES, name insurer

Was medical attendance necessary on Insured or family?

State amount of medical expense & service provider

Give full details of previous losses, if any

Please provide a detailed sketch of the accident / incident

Details of damage

Medical expenses

Injuries and / or damage to property of third parties / passengers & / water skiers

|

Estimated cost of repairs / replacement

Have instructions for repairs been given?

Name & Address Description of injuries / damages Claims received? Amount claim

A

B

C

If a claim has been or is later made against the insured or any communication is received relating to a claim or intended prosecution, inquest or enquiry, it must beimmdeiately sent to the company with full particulars. Do not admit liability or make any offer or promise of payment.

N

S

W E

YES NO

YES NO

YES NO

PAGE 3

Capacity:

Date:

Insured Signature

PAGE 4

Name of Bank

Branch & Code No.

Account No.

Account Type

Name of account Holder

It is recommended that if any amount is payable directly to you, it be transmitted by Electronic Bank Transfer for speedier settlement and security reasons. If you are agreeable to this, please complete and provide the following information

INS

UR

ED

’S B

AN

KIN

G D

ETA

ILS

SMALL CRAFT | PLEASURE CRAFT | HULL CLAIM FORM

I / We hereby declare that the above and foregoing particulars to be true in every aspect