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Marine Cargo
 Claim No.
TOWER
Claim Form
 Date of Loss.
Insurance

PLEASE ANSWER ALL QUESTIONS IN FULL. ANY DELAY IN RETURNING THIS FORM MAY PREJUDICE YOUR CLAIM UNDER THIS POLICY

INSURED NAME :
INSURED ADDRESS :
INSURED EMAIL :

POLICY NO:
CLIENT REFERENCE NO :
VESSEL :
VOYAGE NO:
ARRIVAL DATE :
PORT OF DISCHARGE :
PORT OF SHIPMENT :
DATE LOSS DISCOVERED :

NATURE OF CLAIM :
REMOVE TICK IF NOT APPLICABLE :
PILFERAGE SHORTLANDED DAMAGED     (GIVE BRIEF DESCRIPTION OF TYPE OF DAMAGE)

LIST & DESCRIBE ITEMS CLAIMED FOR : INVOICE VALUE
SUBTOTAL :
FREIGHT CHARGES :
TOTAL :
IF INSUFFICENT SPACE PLEASE ADD NOTES BELOW :

PLEASE MAIL THE FOLLOWING DETAILS :
1.   INVOICE AND COMBINED CERTIFICATE OF VALUE & ORIGIN. 4.   ORIGINAL CERTIFICATE OF INSURANCE (WHEN APPLICABLE)
2.   BILL OF LADING OR OTHER CONTRACT OF CARRAGE 5.   SURVEY REPORT OR OTHER DOCUMENTARY EVIDENCE SHOWING EXTENT OF LOSS OR DAMAGE
3.   WHARF DELIVERY DOCKET 6.   COPIES OF CORROSPONDENCE EXCHANGED WITH CARRIERS AND OTHER PARTIES REGARDING LIABILITY FOR THE LOSS OR DAMAGE
DATE :