The New India Assurance Company Limited
Head Office: 87, M G Road, Fort, Mumbai-400001

SUNDRY HULL CLAIM FORM

ISSUANCE OF THIS FORM IS NOT BE TAKEN AS ADMISSION OF LIABILITY

I. Name of the Insured and Address:

II. Name of the Assignee, if any:

III. Particulars of the Insured Vessel :

a. Name b. GRT

c. Registration No. d. Place of Registration

e. Classified as f. Construction

g. Year Built h. Engine No.

IV. Particulars of the Tindal & Crew Members

Tindal Name & Address

Tindal’s Father Name & Address

Crew Members Name & Address

1. 2.

3. 4.

5. 6.

V. Policy Particulars
No. Issuing Office

Period of Cover Terms

Sum Insured Rs.
VI. Detailed particulars of the casualty giving to this claim indulging place (Anchor-bearing) Time, Date and the cause of the casualty:

VII. Actions taken to save the vessel from imperilment:

VIII. Actual loss / damage suffered :

IX. Human lives lost /saved – How and by whom ?

X. Has the casualty been reported to the authorities – Port Officer / Police / Notary Public ? If so, give particulars:

XI. Was the vessel seaworthy in all respects before commencement of the ill fated voyage or immediately before the casualty?

XII. (a) When was the vessel last repaired ?

(b) What was the repair work carried out?

XIII. Particulars of loss minimization efforts and expenses incurred, if any:

XIV. Estimated Loss :

The above particulars are true to the best of my knowledge. I/We further declare that no other person has any interest in the said properly, as Owner Mortgagee, Trustee of otherwise, and that it is not otherwise insured against with this or any other Office, except as above stated.

Place :

Date :
Signature of Insured.