Boat Insurance Claim Form

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1 Boat Insurance Claim Form 5. Incident Details 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. Date of Occurrence Where did incident occur? Time 1. Your Details Policy Number Name of Insured Expiry Date State Please describe what happened. (Further area for comments and diagram on last page.) Postal Address Contact Name 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 % What purpose was your boat being used for? The property that is the subject of this claim % 3. Your Boat Details Make Model 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. Motor Serial No Trailer brand Rego What was the length of the race? Nautical miles Speed of boat at the time of incident. 4. Type of Claim Collision Theft Fire Malicious Damage Storm Sinking Transit Damage Liability Other. Please specify. What were the weather conditions at the time of the incident: Visibility Good Fair Very Poor Water Calm Moderate Rough Wind Under 15 knots knots knots Over 40 knots

2 6. Own Damage and Liability Claims Name of person operating the boat 9. Loss reduction/salvage Have you taken any other action to recover or reduce your loss? No Yes. If yes, give details. Address State Boat Licence Number Expiry Date 10. Other Parties Was another party injured or their property damaged in this incident? No Yes. If yes, please provide details. Date of Birth Boating Experience / / Years What is the relationship of this person to the insured? Name Address Is it alleged that any person involved in this incident was under the influence of alcohol or a drug? No Yes. If yes, details. Telephone Number If this incident involves another boat or vehicle please provide: Make Model Registration No Colour 7. Theft Claims Name of Insurer Where was the property being claimed for stolen from? Please advise the extent of damage or injuries sustained. Was there evidence of forcible entry or removal? No Yes How did they gain entry or remove the property being claimed? Who do you consider responsible for this incident? Why do you consider this person responsible? 8. Police/Authorities All Incidents Have you reported the incident to police? No Police Station: Yes. Provide details. Date & time reported: Police report number: (Attach copy) 11. Witnesses Name Postal Address If this incident involves a race or speed trial where a protest was lodged please advise the outcome of that protest.

3 12. Ownership and Other Insurance 13. Insured s History Are you the sole owner of the lost or damaged property? No Yes. If no, provide details. 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. 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 Policy Number 14. Schedule 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 Year Purchased 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. 16. Declaration 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. 4. I/We acknowledge that I/We have read and agree to the terms of the Privacy Statement shown below. Insured/s Signature Date

4 ADDITIONAL INFORMATION Please use this area to provide any additional details in relation to this incident. Details of incident Diagram of incident Privcy Act Requirements Your Privacy is important to us. You need to read the Privacy Statement below which explain, amongst other things, how we collect, handle, store and disclose your personal and sensitive information in order for us to provide and inform you about our insurance and insurance related services. To do this we may disclose your personal information to our service providers and others in accordance with the Privacy Statement. The Privacy Policy is located on our website

5 PRIVACY STATEMENT NM Insurance Pty Ltd, ABN , 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 , 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. We may need to disclose information to persons located overseas. Who they are may change from time to time. You can contact us for details or refer to our Privacy Policy available at our website 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 For more information about our privacy practices including how we collect, use or disclose information, how to access or seek correction to your information or how to complain in relation to a breach of the Australian Privacy Principles and how such a complaint will be handled, please refer to our Privacy Policy available at our website or by contacting us (our contact details are below). 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: By In writing: George Street, Sandringham VIC 3191 Effective date: 12 March /14 NM Insurance Pty Ltd T/As Nautilus Marine ABN AFSL George Street, Sandringham Victoria 3191 Phone: Fax: This policy is underwritten by certain underwriters at Lloyd s

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