Marine Claims Notification Form

Insured Name *

City

Tel. *

Policy no(where branch the policy issued)

Type of Cargo *

Date of Damage

Date of Discharge at Port

Voyage: From - To *

Name and Address of Inland transporter

Name

Address

Wereda

Kebele

H.No

Name of Driver

Plate No: Truck

Trailer

Date of Departure from port

Date of Arrival

Air Way Bill

police reportYesNo

Preliminary Survey Report (if any)

Preliminary Survey Report

Description & extent of Damage

Date of Notification *

Signature & Seal *

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