Email* Enter an email address if you would like to receive an emailed notification with the boat claim data on form submission.The issue of this form does not constitute an admission of liability on the part of the insurer.Are you registered for GST purposes?*YesNoHave you claimed an input tax credit on the GST amount applicable to this policy?*YesNoSpecify the percentage amount claimed*What is your Australian Business Number (ABN)?InsuredFull Name*Email*Address* Street Address Work PhoneWork FaxMobileHome PhoneEmailPolicy DetailsPolicy NumberExpiry Date Date Format: MM slash DD slash YYYY Vessel NameRegistrationAccident DetailsLocationDate Date Format: MM slash DD slash YYYY TimeWeather ConditionsSea ConditionsFor what purpose was the vessel being used at the time of the accident? (Tick where applicable) Hire Racing Business Road Transit PleasureWaterborne AccidentsSpeed of vessel at time of accident (power vessels only)Were skiers being towed?YesNoHow manyExplain fully how accident occurredSketch may be attachedHelmsman/Driver (Person in charge at time of accident)Full NameAgeAddress Street Address Work PhoneWork FaxMobileHome PhoneEmailRelationship to Assured (if applicable)Boating LicenceClassHow long has the licence been held?Has the licence ever been endorsed or suspended, or the Helmsman/Driver convicted of any Maritime offence?YesNoPlease give details.Details of Loss or Damage (a quotation for repair will be required)Estimate of LossWhere can the vessel be inspected?Contact NamePhone NumberIn your opinion was the accident your Helmsman’s/Driver’s fault?YesNo(a) Why(b) Have any claims been made on you?(a) Who was to blame(b) Did such person admit any liability?Names of any independent witnessesFull Name of WitnessAddressPhone Police ReportWas the incident reported to the Police or Maritime Authorities?YesNoDid you sign a statement?YesNoOfficer’s NameNumberStationed AtHas any action been taken or threatened?YesNoAgainst whom?CAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms.