PERSONAL WATERCRAFT INCIDENT

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1 claim form PERSONAL WATERCRAFT INCIDENT Insurer: Swann Insurance (Aust) Pty Ltd ABN AFS Licence No YOUR PERSONAL INFORMATION (POLICY HOLDER) Policy No. Title Given name(s) Surname Town/Suburb State Home Phone Business Phone Mobile Phone Preferred Written Contact Method (Australia Post, ) INSURED PERSONAL WATERCRAFT DETAILS Description of personal watercraft involved in the incident Registration No. Year of Manufacture Make/Model/Series Was a trailer involved in the incident? No Yes Type Make Registration No. Do you owe money on the personal watercraft? No Yes Lender s Name Approximate Amount Owing Has the personal watercraft been modified or converted from the manufacturer s specification or fitted with accessories other than those supplied by the manufacturer? No Yes Describe the modifications/accessories $ Was there any unrepaired damage to the personal watercraft before the incident? No Yes Describe the unrepaired damage Is the personal watercraft currently registered? No Yes Expiry date What were you using the personal watercraft for at the time of the incident? (e.g. pleasure, racing, skiing, road transit, moored) 1 of 6

2 Was the personal watercraft being used for skiing or aquaplaning? No Yes How many skiers were being towed? Was there an observer on the personal watercraft? No Yes TYPE OF CLAIM Collision Theft Malicious Damage Storm Sinking Transit Damage Liability Other Please specify PERSON IN CHARGE OF THE PERSONAL WATERCRAFT Who was in charge of the personal watercraft when the incident or theft happened? Relationship to Insured (e.g. son, daughter) Home Phone Business Phone Mobile Phone Did the person in charge of the personal watercraft have the knowledge and consent of the insured? No Yes Current Licence No. Date of Birth Did this person drink any alcohol, or take any drugs or medication in the 12 hours prior to the incident? No Yes What did this person drink or what drugs or medication did this person take? When? How much? Have you ever been charged with, or convicted of a maritime offence or been disqualified from driving a boat/personal watercraft in the past five years? No Yes State the details Have you been charged with, or convicted of, any criminal offence in the last ten years? No Yes Details of prosecutions, penalties, fines, bond imposed Have you ever had insurance declined or cancelled, had a renewal refused or had special conditions imposed by an insurer? No Yes State the reasons INCIDENT DETAILS When did the incident happen? Day Date Time a.m. p.m. Where did the incident happen? 2 of 6

3 How did the incident happen? Describe in detail the circumstances leading up to the incident and how the incident happened. It is important to be as accurate as you can. Please tell us all the facts, even if they are not in your favour. Tell us which person you feel is at fault and why. Using the symbols below draw a diagram of the incident scene showing the position of all vessels and vehicles (if any). Indicate by arrows the direction each was travelling, the north point of the compass, and any relevant information such as street names. Please identify any other vessels or vehicles involved as 2, 3, 4 etc. It is important that the sketch be as accurate as possible as it may be used in legal proceedings. Insured Personal watercraft Other Vessel Swimmers Skiers Your Other Pedestrian, Road Stop Give way Lights vehicle vehicle Cyclist etc. sign sign 2 Please sketch the areas of your personal watercraft damaged in the incident. Your personal watercraft What were the weather conditions at the time of the incident? Fine Overcast Raining Storm Other (specify) What was the speed of the personal watercraft at the time of the incident? What is the estimated cost of repairs if relevant? Please attach a quote. $ If we wish to inspect the personal watercraft, who do we contact and where will the personal watercraft be? Name of Person where the personal watercraft if being kept OTHER PARTIES DETAILS Please provide information about the other parties, even if they were not damaged. This will help our investigation. Owner s Details Full Name Owner s Insurance Company Policy No. Make, Model, Body Type Registration No. Year of Manufacture 3 of 6

4 Details of person in charge of vessel/vehicle Full Name Current Licence No. Date of Birth Please sketch the areas of the other vessels/ vehicles damaged in the incident Vessel/Vehicle (If any other vessels/vehicles were involved, please attach details of those vessels/vehicles not mentioned above on a separate sheet) As a result of the incident, was there any other property damaged (e.g. buoys, fences, telephone poles)? No Yes Provide details Name of Property Owner Was anyone injured as a result of the incident? No Yes the driver or passenger Person s Surname Given Name(s) Age Nature of injuries If taken to hospital, state the name of the hospital Have you received a claim from the injured person or the owner of the damaged property? No Yes Attach any correspondence relating to this claim Were there any witnesses to the incident? No Yes Name if Witness Type of Witness: Passenger In Insured s Personal Watercraft Other Vessel/Vehicle Independent Eye Witness Did the police attend the incident? No Yes Officer s Name Name of Station Was the incident reported to a police station? No Yes Officer s Name Name of Station Date Police Report No. 4 of 6

5 Was any driver or person in charge of any vessel/vehicle asked to take a blood/breathalyser test? No Yes Insured Driver/Person The Result % Other Driver/Person The Result % Was any person charged with an offence or offences or advised that charges may be laid? No Yes Insured Person and the offence(s) Other Person and the offence(s) THEFT DETAILS What was stolen? Personal watercraft Accessories Please list When was the personal watercraft last seen? Day Date Time a.m. p.m. Who last saw the personal watercraft? Full Name Relationship to Insured (e.g. son, employee) Home Phone Business Phone Facsimile No. Who discovered the theft and when? Full Name Date Time a.m. p.m. Do you know who is responsible for the theft? No Yes State the names and addresses or any other identifying information To which police station was the theft reported? Officer s Name Name of Station Date Reported Time Police Report No. a.m. p.m. Was the personal watercraft recovered? No Yes Explain the circumstances surrounding the recovery (e.g. who, when, where) If damaged, provide details Please sketch the areas of your personal watercraft damaged in the theft. Your personal watercraft 5 of 6

6 DECLARATION 1. I/we declare that to the best of my/our knowledge and belief the particulars in this form are true and correct and I/we have not withheld any relevant information. 2. I/we undertake to give all assistance in dealing with this matter. 3. I/we authorise Swann Insurance (Aust) Pty Ltd (Swann) to procure any or all relevant information from a relevant regulatory or law enforcement authority. 4. I/we agree that a signed copy of this declaration/authority may be utilised as if it were the original. 5. I/we consent to Swann using my/our personal information I/we have provided on this form for the purpose of processing this claim. I/we understand that if I/we choose not to provide the required details, Swann may not be able to process this claim. 6. I/we consent to Swann disclosing my/our personal information to other insurers, an insurance reference service, the financier, its service providers and/or advisors, any third party with whom I/we have been dealing in respect of this insurance and who referred me/us to Swann, and any other party as permitted or required by law. I/we consent to Swann also disclosing my/our personal information to and/or collecting additional information about me/us from investigators or legal advisors. 7. I/we hereby authorise Swann to move the personal watercraft to any place of storage or repair and take any other action Swann considers necessary to implement repair or reinstatement of the personal watercraft. 8. I/we agree that, by submitting this form the personal information I/we provide to Swann in this form or otherwise may be collected, held, used and disclosed in a manner set out in the Swann Privacy Policy found at including for processing this claim. Signature of the insured or person with authority sign for and on behalf of a company or partnership Date Signature of the person in charge of the personal watercraft (if not the insured) Date Please indicate the number of additional pages attached to this claim report: When complete, please forward the report to: - swann.pwc.claims@swanninsurance.com.au Post - Swann Insurance (Aust) Pty Ltd, Locked Bag 3275 Melbourne VIC of 6

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