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    marine-insurance-cargo-claim-form

    Uploaded by

    Gnanes Waran

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    marine-insurance-cargo-claim-form

    Uploaded by

    Gnanes Waran
    4 views3 pages

    Copyright

    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    4 views3 pages

    marine-insurance-cargo-claim-form

    Uploaded by

    Gnanes Waran

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 3

    MARINE INSURANCE - CARGO

    CLAIM FORM
    Please note that the issue of this claim form is not to be taken as an admission of liability

    Policy / Certificate No: Claim No:


    Name:
    Address:

    Insured Details
    Contact Person:
    E-mail: Fax:
    Tel (s): Mobile no
    Name
    Contact Person:
    Consigner Details
    E-mail: Fax:
    Tel (s): Mobile no
    Names
    Consignee Contact Person:
    Details E-mail: Fax:
    Tel (s): Mobile no
    Place of departure Place of arrival
    Date of departure Date of arrival
    Nature of Goods
    Name of
    Transport Details Means of Transport Carrier/ forwarder

    Value of Goods Packing


    Consignment Note
    Consignment Note No:
    Date:

    Claim Form_ Marine Insurance - Cargo UIN: IRDAN132RP0013V01200708 Page 1 of 3


    Future Generali India Insurance Company Limited
    Date when goods reached Date of taking
    destination town/railway delivery at the
    station/port of discharge: final
    Transport Details destination:
    Reasons for delay for
    taking delivery at final
    destination , if any :
    Was the damage visible on Date of Notice
    arrival? of Loss
    Yes /No
    Place of Notice of Loss Description of
    damage.

    Cause of Loss Type and extent


    of Loss
    Location of damaged
    goods
    Loss Details
    If damaged in transit, was steamer survey held
    or open delivery taken? If so attach certificates
    from the carrier
    Written notifications of loss send against
    carrier?
    Yes / No
    If Yes, attach copy, if No, give reasons
    Total Claim Amount (In Rs)

    Name and address of Name and address


    Payment To beneficiary of bank and account
    no.
    Damaged goods must be kept for survey. Please take all necessary steps to minimize the
    loss and prevent further damage.
    Please Note
    Please ensure that the recovery rights against the Carrier / Third party are protected

    Claim Form_ Marine Insurance - Cargo UIN: IRDAN132RP0013V01200708 Page 2 of 3


    Future Generali India Insurance Company Limited
    1. Way bill, B/L, airway bill etc. 2. Original Insurance policy/ certificate if any 3.
    Commercial invoice 4. Survey report. 5. Delivery receipts/ notes 6. Cost of repair receipts
    Please Attach
    or estimate 7.
    Copy of notification of loss to carrier 8. Other relevant correspondence/ documents.

    Declaration
    I/We agree to provide additional information to the company, if required. I/We the above mentioned, do
    hereby, to the best of my/our knowledge and belief, warrant the truth of the foregoing statement in every
    respect, and if I/We have made, or in any further declaration the company may require in respect of the said
    accident, shall make any false or fraudulent statement, or any suppression or concealment, the policy shall
    be void and all rights to recover there under in respect of past or future accident shall be forfeited.

    Place:

    Signature & company seal of the


    Date:
    insured

    Claim Form_ Marine Insurance - Cargo UIN: IRDAN132RP0013V01200708 Page 3 of 3


    Future Generali India Insurance Company Limited

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