Marine Claim Reporting Form

Fill out as completely as possible and click Submit to send the loss report to our Marine and Transportation Specialty Claims Unit (MATSCU). Alternately, you can print this page, complete the form and fax it to the MATSCU at 1-877-629-6905.

Claim Reported By:

Firm Name (if other than Assured):

Individual's Name:

Phone No.:

Fax No.:

Email Address:

Relationship to Assured:

Assured

Consignee

Insurance Agent/Broker

Name of Assured:

Open Policy No.:

Special Cargo Policy No. if issued:

Shipper’s Name, if other than Assured:

Consignee’s Name, if other than Assured or Firm requesting Claim Representative:

Details of Insurance (if known)

Value of Shipment:

Deductible:

Voyage From:

To:

Name of Vessel/Conveyance:

Arrival Date:

Survey Threshold Amount, if known (see reverse of Special Cargo Policy):

Details of Shipment (if known)

Bill of Lading Number:

BOL Date:

Description of Cargo:

Marks and Numbers:

Location of Shipment:

Estimated Amount of Damage:

Description of Damage:

Has a surveyor been assigned?

Yes

If Yes, indicate name of firm and contact phone or fax no.:

Has carrier been notified of claim?

Yes

Contact Person for Further Details (if other than individual shown at top):

Name:

Phone No.:

Fax No.:

Email Address: