Boat Insurance Claim Form
5. Incident Details
Date of Occurrence Time
Where did incident occur?
Please describe what happened. (Further area for comments and diagram on last page.)
What purpose was your boat being used for?
If your boat was being used for a race or a speed trial, was it a: Club Event or a Named Race Please provide details.
What was the length of the race?
Nautical miles Speed of boat at the time of incident.
What were the weather conditions at the time of the incident: Visibility Good Fair Very Poor
Water Calm Moderate Rough
Wind Under 15 knots 15-29 knots 30-40 knots Over 40 knots The issue or acceptance of this form is not to be construed as an
admission of liability on the part of the Company.
Please provide complete details to the questions asked on this form. If there is insufficient space for your answers please use the Additional Information section on the back of this form.
1. Your Details
Policy Number Expiry Date
Name of Insured
Postcode Contact Name
Home Phone Number Work / Mobile Number
2. Goods and Services Tax (GST)
Are you registered for GST? No Yes. If yes, provide your ABN number.
What is your entitlement to an Input Tax Credit in respect of:
Your boat insurance premium %
The property that is the subject of this claim % 3. Your Boat Details
Motor Serial No
Trailer brand Rego
4. Type of Claim
Collision Theft Fire Malicious Damage Storm Sinking
Transit Damage Liability Other. Please specify.
6. Own Damage and Liability Claims
Name of person operating the boat
Home Phone Number Work / Mobile Number
Boat Licence Number Expiry Date
Date of Birth Boating Experience / / Years What is the relationship of this person to the insured?
Is it alleged that any person involved in this incident was under the influence of alcohol or a drug? No Yes. If yes, details.
7. Theft Claims
Where was the property being claimed for stolen from?
Was there evidence of forcible entry or removal? No Yes How did they gain entry or remove the property being claimed?
8. Police/Authorities – All Incidents
Have you reported the incident to police? No Yes. Provide details.
Police Station: Date & time reported: Police report number: (Attach copy)
If this incident involves a race or speed trial where a protest was lodged please advise the outcome of that protest.
9. Loss reduction/Salvage
Have you taken any other action to recover or reduce your loss? No Yes. If yes, give details.
10. Other Parties
Was another party injured or their property damaged in this incident? No Yes. If yes, please provide details.
Postcode Telephone Number
If this incident involves another boat or vehicle please provide: Make Model
Registration No Colour Name of Insurer
Please advise the extent of damage or injuries sustained.
Who do you consider responsible for this incident?
Why do you consider this person responsible?
12. Ownership and Other Insurance
Are you the sole owner of the lost or damaged property? No Yes. If no, provide details.
Are you able to make a claim with another insurance company for any of the property you are claiming now?
No Yes. If yes, provide details. Name of Insurer
13. Insured’s History
Have you ever – had previous claims? No Yes – been refused insurance? No Yes – been charged/convicted
of any offence? No Yes If you answered Yes to any of the above provide details.
Please provide full details of your loss. If there is insufficient space below please show additional details on the back of this claim form.
Description of Property Lost/damaged/stolen PurchasedYear Estimated Value Cost of Repairs(if damaged)
To avoid delays in processing your claim, please attach all original repair invoices, receipts or replacement quotes to this form. Proof of ownership is required for stolen or lost items, i.e. original purchase invoices, receipts, valuations, etc.
15. Claims Procedure
What you need to do:
• Take every reasonable precaution to prevent further loss, damage, cost or liability;
• Notify the police as soon as possible if the incident involves injury, theft, attempted theft, malicious acts, or impact by a boat or vehicle; • Notify us as soon as possible about the claim;
• Assist us to manage the claim. This may include us inspecting your boat, interviewing you, or you providing written statements to us under oath;
• Provide us with all reasonable proof that we require in respect of lost or damaged items claimable under this policy; • Keep items that have been damaged and make them available for inspection or assessment of repair costs; • Allow us to take possession of damaged property that is the subject of a claim.
You must not:
• Admit guilt, fault, or liability (except to the Police);
• Approve any repairs or arrange replacements (other than emergency repairs reasonably necessary to protect your boat against further loss or damage);
• Dispose of any damaged property.
1. I/We will notify Nautilus Marine immediately where this claim is for lost or stolen property and any of it is found.
2. I/We certify that the information given in this form is truthful accurate and complete. No information likely to affect this claim has been withheld. I/ We understand that this claim may be refused if information is untrue, inaccurate or concealed.
3. I/We authorise Nautilus Marine to give to, or obtain from, other insurers or any insurance reference bureau, any information relating to this claim or any other claim made by me/us or any insurance held by me/us.
ADDITIONAL INFORMATION – Please use this area to provide any additional details in relation to this incident.
Privcy Act Requirements
Details of incident
Diagram of incident
NM Insurance Pty Ltd T/As Nautilus Marine
ABN 34 100 633 038 AFSL 227186
28-32 George Street, Sandringham Victoria 3191
Phone: 1300 780 533 Fax: 03 8599 5099
This policy is underwritten by certain underwriters at Lloyd’s.
NM Insurance Pty Ltd, ABN 34 100 633 038, trading as Nautilus Marine are committed to protecting your privacy in accordance with the Privacy Act 1988 (Cth) (Privacy Act) and the Australian Privacy Principles (APPs).
This Privacy Statement outlines how we collect, disclose and handle your personal information (including sensitive information) as defined in the Act. Why we collect your personal information
We collect your personal information (including sensitive information) so we can: • identify you and conduct necessary checks;
• determine what service or products we can provide to you e.g. offer our insurance products;
• issue, manage and administer services and products provided to you or others, including claims investigation, handling and settlement; • improve our services and products e.g. training and development of our representatives, product and service research and data analysis and
business strategy development;
• make special offers of other services and products provided by us or those we have an association with, that might be of interest to you. What happens if you don’t give us your personal information?
If you choose not to provide us with the information we have requested, we may not be able to provide you with our services or products or properly manage and administer services and products provided to you or others.
How we collect your personal information
Collection can take place by telephone email, or in writing and through websites (from data you input directly or through cookies and other web analytic tools).
We collect it directly from you unless you have consented to collection from someone other than you, it is unreasonable or impracticable for us to do so or the law permits us to.
If you provide us with personal information about another person you must only do so with their consent and agree to make them aware of this privacy notice.
Who we disclose your personal information to
We share your personal information with third parties for the collection purposes noted above.
The third parties include: our related companies and our representatives who provide services for us, Lloyd’s, our insurers, other insurers and reinsurers, your agents, our legal, accounting and other professional advisers, data warehouses and consultants, social media and other similar sites and networks, membership, loyalty and rewards programs or partners, providers of medical and non-medical assistance and services, investigators, loss assessors and adjusters, other parties we may be able to claim or recover against, and anyone either of us appoint to review and handle complaints or disputes and any other parties where permitted or required by law.
In some cases we may not be able to take reasonable steps to ensure they do not breach the Privacy Act and they may not be subject to the same level of protection or obligations that are offered by the Act. By proceeding to acquire our services and products you agree that you cannot seek redress under the Act or against us (to the extent permitted by law) and may not be able to seek redress overseas.
More information, access, correction or complaints
Contact us and opting out
By proceeding with your application or submitting your claim, you and any other person included on the policy, consent to this use and these disclosures unless you tell us otherwise. If you wish to withdraw your consent, including for things such as receiving information on products and offers by us or persons we have an association with, please contact us.
By phone: 1300 780 533
By email: firstname.lastname@example.org In writing: 28-32 George Street, Sandringham VIC 3191 Effective date: 12 March 2014