MARINE INSURANCE CLAIM

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NOTICE OF LOSS AND CLAIM

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[LETTERHEAD]

DATE: [__/__/____]

TO:
[________________________________]
[Insurance Company/P&I Club Name]
[________________________________]
[________________________________]
[________________________________]

VIA: [☐ Email] [☐ Certified Mail] [☐ Courier] [☐ Online Portal]

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IMMEDIATE NOTICE OF MARINE LOSS

CLAIM TYPE:
☐ Hull and Machinery (H&M)
☐ Cargo Insurance
☐ Protection and Indemnity (P&I)
☐ Freight Insurance
☐ War Risk
☐ [________________________________]

POLICY INFORMATION:

Field	Information
Policy Number	[________________________________]
Certificate Number (if applicable)	[________________________________]
Policy Period	[__/__/____] to [__/__/____]
Insured Name	[________________________________]
Insured Address	[________________________________]
Broker Name	[________________________________]
Broker Contact	[________________________________]

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I. INSURED PROPERTY

A. For Hull and Machinery Claims:

Vessel Information	Details
Vessel Name	[________________________________]
IMO Number	[________________]
Official Number	[________________]
Flag State	[________________________________]
Port of Registry	[________________________________]
Gross Tonnage	[________________]
Year Built	[____]
Classification Society	[________________________________]
Insured Value	$[________________]

B. For Cargo Claims:

Shipment Information	Details
Bill of Lading Number	[________________________________]
Vessel Name	M/V [________________________________]
Voyage	[________________________________] to [________________________________]
Loading Date	[__/__/____]
Discharge Date	[__/__/____]
Cargo Description	[________________________________]
Quantity	[________________________________]
Invoice Value	$[________________]
Insured Value	$[________________]

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II. THE LOSS/INCIDENT

A. Date and Time of Loss

Date of Loss/Discovery: [__/__/____]
Time of Loss/Discovery: [____] hours
Date Loss First Reported: [__/__/____]

B. Location of Loss

☐ At Sea - Position: [________________________________]
☐ In Port - Port Name: [________________________________]
☐ In Transit - Location: [________________________________]
☐ [________________________________]

C. Description of Loss/Incident

Please describe in detail what happened:

[________________________________]
[________________________________]
[________________________________]
[________________________________]
[________________________________]
[________________________________]

D. Type of Loss

☐ Actual Total Loss (ATL)
☐ Constructive Total Loss (CTL)
☐ Partial Loss
☐ General Average
☐ Salvage
☐ Sue and Labor Expenses
☐ Third Party Liability
☐ Collision/Allision
☐ Pollution/Environmental
☐ Personal Injury/Death
☐ [________________________________]

E. Cause of Loss

☐ Fire/Explosion
☐ Collision
☐ Grounding
☐ Heavy Weather/Storm
☐ Machinery Breakdown
☐ Water Ingress/Flooding
☐ Theft/Pilferage
☐ Piracy
☐ War/Civil War
☐ Contamination
☐ Temperature Deviation
☐ Improper Stowage
☐ Rough Handling
☐ [________________________________]

F. Weather and Sea Conditions (if relevant)

Wind: [________________________________]
Sea State: [________________________________]
Visibility: [________________________________]
Other Conditions: [________________________________]

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III. EXTENT OF LOSS/DAMAGE

A. For Vessel Damage:

Description of Damage:
[________________________________]
[________________________________]
[________________________________]

Affected Areas/Systems:
☐ Hull
☐ Main Engine
☐ Auxiliary Machinery
☐ Steering Gear
☐ Navigational Equipment
☐ Cargo Holds
☐ [________________________________]

Temporary Repairs: [☐ Completed] [☐ Planned] [☐ Not Needed]
Location: [________________________________]
Estimated Cost: $[________________]

Permanent Repairs:
Repair Yard: [________________________________]
Estimated Cost: $[________________]
Estimated Time: [____] days

B. For Cargo Damage:

Description of Damage:
[________________________________]
[________________________________]

Extent:
☐ Total Loss - [____]% of shipment
☐ Partial Loss/Damage - [____]% of shipment
☐ Concealed Damage

Cargo Survey:
Surveyor: [________________________________]
Survey Date: [__/__/____]
Survey Reference: [________________________________]

Disposition of Damaged Cargo:
☐ Held pending instructions
☐ Sold at salvage value of $[________________]
☐ Disposed/Condemned
☐ [________________________________]

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IV. THIRD PARTIES INVOLVED

A. Other Vessels (if collision):

Vessel Name	Flag	Owner	Insurer
[________________________________]	[____]	[________________________________]	[________________________________]

B. Third Party Claimants (if P&I):

Name	Nature of Claim	Estimated Amount
[________________________________]	[________________________________]	$[________]
[________________________________]	[________________________________]	$[________]

C. Other Parties:

Salvors: [________________________________]
Port Authority: [________________________________]
Classification Society: [________________________________]
Coast Guard: [________________________________]

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V. ACTIONS TAKEN TO MINIMIZE LOSS

Pursuant to the sue and labor clause, the following actions were taken to minimize the loss:

☐ Emergency repairs
☐ Salvage operation
☐ Cargo transfer
☐ Firefighting
☐ Pollution containment
☐ Hiring of surveyors
☐ Security measures
☐ [________________________________]

Sue and Labor Expenses Incurred:

Expense	Amount
[________________________________]	$[________]
[________________________________]	$[________]
[________________________________]	$[________]
TOTAL	$[________]

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VI. CLAIM AMOUNT

A. Preliminary Estimate of Claim:

Item	Amount
Property Damage/Loss	$[________________]
Sue and Labor Expenses	$[________________]
Survey Fees	$[________________]
Salvage Charges	$[________________]
General Average Contribution	$[________________]
Third Party Liability	$[________________]
[________________________________]	$[________________]
GROSS CLAIM AMOUNT	$[________________]
Less: Deductible	($[________________])
NET CLAIM AMOUNT	$[________________]

B. Policy Deductible:

Per-Occurrence Deductible: $[________________]
Annual Aggregate Deductible: $[________________]
Deductible Already Applied This Policy Year: $[________________]

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VII. COVERAGE CONFIRMATION

We believe this loss is covered under the above-referenced policy based on:

☐ Institute Cargo Clauses (A) - All risks coverage
☐ Institute Cargo Clauses (B) - Named perils (includes fire, explosion, collision, jettison, etc.)
☐ Institute Cargo Clauses (C) - Named perils (more limited)
☐ Institute Time Clauses - Hulls
☐ American Institute Hull Clauses
☐ P&I Club Rules
☐ Other: [________________________________]

Applicable Clause/Coverage:
[________________________________]

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VIII. DOCUMENTATION ENCLOSED/TO FOLLOW

Enclosed with this Notice:

☐ Copy of Insurance Policy/Certificate
☐ Bill of Lading
☐ Commercial Invoice
☐ Packing List
☐ Survey Report (Preliminary)
☐ Photographs
☐ Vessel Documentation
☐ Protest Note
☐ [________________________________]

To Follow:

☐ Final Survey Report
☐ Repair Estimates/Invoices
☐ Classification Society Report
☐ Coast Guard Report
☐ Cargo Manifest
☐ Weather Reports
☐ Deck/Engine Log Extracts
☐ [________________________________]

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IX. RESERVATION OF RIGHTS

This notice is provided without prejudice to any rights of the Insured under the policy or at law. The Insured reserves all rights to:

☐ Amend this claim based on additional information
☐ Claim additional amounts as they become known
☐ Pursue recovery against third parties
☐ All other rights under the policy and applicable law

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X. CONTACT INFORMATION

For All Communications Regarding This Claim:

Primary Contact: [________________________________]
Title: [________________________________]
Company: [________________________________]
Address: [________________________________]
Telephone: [________________________________]
Mobile: [________________________________]
Email: [________________________________]

24-Hour Emergency Contact:
[________________________________]
[________________________________]

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XI. AUTHORIZATION

I/We hereby authorize:

☐ The appointment of a surveyor by the Underwriters
☐ Access to the vessel/cargo for survey purposes
☐ Release of information from third parties as necessary for this claim

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XII. DECLARATION

I/We declare that the information provided in this notice is true and accurate to the best of my/our knowledge and belief. I/We understand that any misrepresentation may void coverage under the policy.

______________________________________
Signature of Insured or Authorized Representative

Name: [________________________________]
Title: [________________________________]
Date: [__/__/____]

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IMPORTANT REMINDERS

IMMEDIATE ACTIONS REQUIRED:

1. ☐ Notify your insurance broker immediately
2. ☐ Take all reasonable steps to minimize/prevent further loss
3. ☐ Preserve all evidence (photos, documents, damaged property)
4. ☐ Do not dispose of damaged property without surveyor approval
5. ☐ File protest note at first port of call (if vessel incident)
6. ☐ Notify classification society (if vessel incident)
7. ☐ Report to authorities as required (Coast Guard, Port State, etc.)
8. ☐ Do not admit liability to third parties

TIME LIMITS:

• Notice of loss: As soon as possible / [____] days per policy
• Proof of loss: [____] days per policy
• Suit filing: [____] years per policy

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PROOF OF LOSS FORM (To Be Completed Later)

PROOF OF LOSS

The undersigned, being duly sworn, deposes and says:

1. Insured: [________________________________]
2. Policy Number: [________________________________]
3. Date of Loss: [__/__/____]
4. Location of Loss: [________________________________]
5. Cause of Loss: [________________________________]
6. Description of Damaged Property: [________________________________]
7. Total Amount of Loss: $[________________]
8. Less: Deductible: $[________________]
9. Amount Claimed: $[________________]
10. No other insurance covers this loss except: [________________________________]
11. This loss was not caused by any act, neglect, or procurement of the Insured.

Sworn to and subscribed before me this [____] day of [________________], 20[____].

______________________________________
Notary Public

______________________________________
Insured Signature

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SOURCES AND REFERENCES

• Institute Cargo Clauses: https://www.lmalloyds.com/LMA/Underwriting/Marine/JCC/JCC.aspx
• American Institute Clauses: https://aimu.org/
• Marine Insurance Overview: https://www.iii.org/article/insuring-marine-businesses-and-cargo
• P&I Club Rules: Contact your specific P&I Club