Marine Cargo Claim Form

This field is for validation purposes and should be left unchanged.

Insured Details

Name of the Insured*

Trading Name

Policy Number*

ABN*

Are you Registered for GST?

Yes

Input Tax Credit Entitlement %

Name of the Person Providing Information*

Phone Number of the Person Providing Information*

Email*

Occupation Details*

Incident Details

Date of Incidence*

Time of Incidence*

Location of Incidence*

Weather Conditions*

Road Conditions*

Estimated speed of your vehicle*

Estimated speed of other vehicle, if involved

Driver was Driving from*

Driver was Driving to*

The purpose of journey was*

Distance from your base of operation to the incident scene

Incidence Details*

Was another vehicle involved in the incident?*

Yes

Third Party Motor Vehicle & Driver Details

Make

Model

Year

Engine Number

VIN Number

Rego Number*

Third Party Driver Full Name*

Type of Licence*

State Where Licence is Issued*

Licence Number*

Email*

Phone Number*

Freight Details

Was there any Load carried in your Vehicle?*

Yes

Type of Load being carried at the time of accident*

Weight of load being carried (kg)*

Where is the freight now? (Please provide detailed address & contact number)

Contact Person Name

Phone Number

Address

Please state the exact location where the loss or damage occurred

Who first noticed the loss or damage & when (date)?

Was there any pre-existing damage to the freight?*

Yes

Please provide details*

Responsible Party

In your opinion, who is responsible for the incidence?*

Insured or their Employee;

Contractor or Sub-contractor;

Third party

What is your reason for thinking so?*

If your vehicle was towed, do you consider the tow operator being responsible for any part of the freight damage?

Contractor / Sub-contractor or Third Party Details

If you consider the Contractor / Sub-contractor or Third Party to be responsible, please provide details below:

Full Name

Address

Phone Number

Witness Details

Were there any witnesses to the incident?*

Yes

Witness Details

Witness Name*

Witness Address

Witness Phone Number*

Witness Email Address*

Add more

Party Claiming Against You

Name*

Address

Phone*

Please Complete the Below Table if Marine Cargo Claim is Made Against You

Item Description

Quantity

Invoice or Insured Value

Total Invoice Value

Estimated Repair or Replacement Cost ($)

If You Need to Provide More Details

Documents Attached

Photos of the incident*

Yes

Quotes / Invoices*

Yes

Photos of the incident

Drop files here or

Max. file size: 100 MB.

Quotes / Invoices

Drop files here or

Max. file size: 100 MB.

Licence copy (front and back)*

Yes

Declaration

I/We declare that to the best of my knowledge these particulars are truthful, accurate and complete

Signature*

Full Name*

On Behalf Of*

Date*

Insured Details

Insured Vehicle

Trailer Info

Insured Vehicle Driver's Details

Did the driver of the vehicle undergo any of the following test?

Incident Details

Third Party Motor Vehicle & Driver Details

Freight Details

Where is the freight now? (Please provide detailed address & contact number)

Responsible Party

Contractor / Sub-contractor or Third Party Details

If you consider the Contractor / Sub-contractor or Third Party to be responsible, please provide details below:

Witness Details

Party Claiming Against You

Documents Attached

Declaration

If Existing Business

Insured Details

Director/ Owner

Policy

Duty Of Disclosure

If Existing Business

Insured Details

Director/ Owner

Policy

Duty Of Disclosure

Marine Cargo Claim Form

Insured Details

Insured Vehicle

Trailer Info

Insured Vehicle Driver's Details

Did the driver of the vehicle undergo any of the following test?

Incident Details

Third Party Motor Vehicle & Driver Details

Freight Details

Where is the freight now? (Please provide detailed address & contact number)

Responsible Party

Contractor / Sub-contractor or Third Party Details

If you consider the Contractor / Sub-contractor or Third Party to be responsible, please provide details below:

Witness Details

Party Claiming Against You

Documents Attached

Declaration

If Existing Business

Insured Details

Director/ Owner

Policy

Duty Of Disclosure

If Existing Business

Insured Details

Director/ Owner

Policy

Duty Of Disclosure

This questionnaire should be completed in conjunction with the ISP Proposal Form. When completed, please sign this questionnaire where indicated, ensuring that prior to signing you have read and understand Your Duty of Disclosure and our Privacy statement.

Section A: General Information

Section B: Machines to be insured

The age of the pumping unit must be supplied

Truck

Pump

Section C: Maintenance And Accreditation

Who undertakes maintenance / servicing of concrete pumping machines?

Section D: Claims and/or circumstances

Who undertakes maintenance / servicing of concrete pumping machines?

Your duty of disclosure

QBE Privacy

UAA Privacy

Declaration

General Information