Claims | Nautical Insurance

All questions on this form must be clearly and fully answered, otherwise processing of this claim may be delayed until the required information is supplied.

If any question does not apply to the circumstances of your claim, it must be marked “not applicable”.

The insurers do not admit liability by the issue of this form.

Policy Details

Policy number

Excess

Client number

Person completing claim form*

Forename Surname

Email*

Phone*

PO box / street*

Suburb / rural delivery

City / town*

Postcode*

Vessel Details

Name

Type*

Incident Details

Time*

: HH

mm

Date*

Location*

What happened*

Speed

Weather conditions

Good
Fair
Very poor

Water conditions

Calm
Moderate
Rough

Tide

Low
Mid
High

Wind speed (knots)

Under 15
15-29
30-40
Over 40

Purpose for which the vessel being used*

Other purpose

Helm person at the time of the incident

Relationship of helm person to the insured

Helm person (or driver towing the vehicle) had consumed any intoxicating liquor or taken any drug within 12 hours of the incident*

Yes
No

Name of liquor/drug

Quantity taken

Period of consumption

Full details of the damage to the insured vessel*

Assessment Details

Address where vessel can be inspected

Street Suburb City / town

Estimate for cost of repairs obtained

Yes
No

Estimate amount ($)

Estimate done by

Action (if any) taken to minimise loss/damage or liability

Ownership Details

You own all the damaged/lost property*

Yes
No

Owner name

Owner address

Street Suburb City / town

You have any other insurance that covers this claim*

Yes
No

Sum insured ($)

Company

Branch

Theft Details

If burglary / theft / loss / malicious damage occurred, the police have been notified*

Yes
No
Not applicable

Station reported to

Date

Other Parties

No liability should be admitted by you, or any offer made to compensate for damage
All communications recieved should be forwarded to us immediately

You consider the incident to be the fault of any person other than yourself*

Yes
No

Details regarding the other person's culpability for the incident

The other person admitted liability

Yes
No

Details of the admission of liability

Please give details of the owner of the other vessel or property

Name

Address

PO box / street Suburb / rural delivery City / town Postcode

Phone

Damage to other property (if applicable)

Protest lodged at the racing event

Yes
No

Outcome of the protest

Names and addresses of all witnesses (include all passengers in your vehicle)

Name	Address	Actions

There are no Witnesses.

Hidden

Sketch plan and/or photos if available

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Sketch plan and photos if available

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Declaration (please scroll down to read)*

I/we declare that to the best of my/our knowledge and belief these particulars are complete and accurate. I/we have not withheld any information or details of previous claims or any other material fact likely to affect acceptance of this claim.

I/we:

a. Agree to give any further information required;

b. Understand you require this personal information, which will be retained by Nautical / Vero NZ Limited before you can evaluate my/our claim;

c. Authorise the disclosure of this personal information regarding the claim to other parties;

d. Authorise the obtaining by Nautical / Vero NZ Limited from any other party personal information about me/us that is in your view relevant to this claim;

e. Authorise the obtaining by Nautical / Vero NZ Limited from any other party personal information about me/us that is in your view relevant to this claim;

f. Authorise Vero NZ Limited to place details of this claim on the database of "ICR Ltd, PO Box 474, Wellington", where it will be retained and available to other insurance companies to inspect;

g. Understand that I am/we are entitled to have certain rights of access to and correction of the personal information held by Vero and ICR Ltd.

I agree