Marine cargo claim form - Truck Insurance HQ
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    The insured




    Driver or person in charge of the vehicle












    A photocopy of both sides if license and log book (where applicable) must be attached




    YesNo

    Was any intoxicating liquor or drugs (includeing prescription drugs) consumed in the 12 ours
    preceding the accident or transit journey?

    YesNo

    Did the driver or person in control of the vehicle undergo a breathalyser / blood test / urine or
    oral fluid test / drug impairment assessment?

    YesNo
    Breathalyser:
    YesNo

    Blood test:
    YesNo

    Vehicle information

    prime vehicle(if involved)







    Trailer(if involved)







    Transit and incident details

    Date and time of transit









    Freight owner(s) claimant(s) details





    YesNo
    Please provide name and address of other carrier(s)

    You need to set an ID to this group. Use [field_group your_custom_id] format.


    YesNo

    Is police action pending:
    YesNo
    Were there any witness(es):
    YesNo



    Consignment notes / Term and conditions

    SubcontractorPrincipal/Sole carrier

    YesNo



    YesNo



    YesNo

    YesNo



    YesNo


    Details of other vehicles / persons involved




    Owner detail:



    Details of cargo loss and claims made




    YesNo


    YesNo


    YesNo


    This section only to be completed if marine cargo claim is made against you



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