282790 0415 G3926 v4 FINAL - motorcycledirect.com.au
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YOUR PERSONAL INFORMATION (POLICY HOLDER) Title Given name(s) Surname Address Town/Suburb State Postcode Home Phone Business Phone 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. Was a motor involved in the incident? No Yes Type Make Registration No. 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) claim form BOAT INSURANCE INCIDENT Policy No. Insurer: Insurance Australia Limited ABN 11 000 016 722 AFS Licence No 227681 trading as Swann Insurance (Swann Insurance). 1 of 7 G3926 0817 PRN_K535
Transcript of 282790 0415 G3926 v4 FINAL - motorcycledirect.com.au
YOUR PERSONAL INFORMATION (POLICY HOLDER)
Title Given name(s) Surname
Address
Town/Suburb State Postcode
Home Phone Business Phone 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.
Was a motor involved in the incident?
No Yes Type Make Registration No.
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)
claim form
BOAT INSURANCE INCIDENT
Policy No.Insurer: Insurance Australia Limited ABN 11 000 016 722 AFS Licence No 227681 trading as Swann Insurance (Swann Insurance).
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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.
Swimmers Skiers LightsRoadInsured Boat Stop sign
Give way sign
Other Vessel
Your vehicle
Other vehicle
2
Pedestrian, Cyclist etc.
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 Registration No. Year of Manufacture
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Details of person in charge of vessel/vehicle Full Name Telephone No.
Current Licence 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 Postcode
Home Phone 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?
No Yes 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.
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 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 Insurance 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 Insurance may not be able to process this claim.
6. I/we consent to Swann Insurance 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 Insurance, and any other party as permitted or required by law. I/we consent to Swann Insurance 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 Insurance to move the boat to any place of storage or repair and take any other action Swann Insurance 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 Insurance in this form or otherwise may be collected, held, used and disclosed in a manner set out in the Swann Insurance 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 Date
/ /
Signature of the person in charge of the boat (if not the insured) 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, Locked Bag 3275 Melbourne VIC 3001
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