REPORT A CLAIM
Insured information
Individual
Organization
Name
Mailing address
City
State
Select...
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
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NJ
NM
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NY
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OK
OR
PA
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SC
SD
TN
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UT
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VT
WA
WI
WV
WY
Zip code
E-mail Address
Home Phone #
Cell Phone #
Work Phone #
Alt Phone #
Your relationship to insured
Self
Other
Operator at time of loss (if applicable)
Insured
Preparer
Other
Claim information
Policy #
Year, make and model
Hull ID
Date of loss
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
Year
2013
2012
Time of Loss
Loss Location
On Land
On Water
Damage or loss caused by
Theft of Equipment
(permanently attached to craft)
Theft of Personal Property
(should also be reported on Homeowner's policy)
Theft of Craft
Theft of Trailer
Fire
Lightning
Flood
Wake
Freezing
Vandalism
Corrosion
Animal
Windstorm/Hurricane
Wear & Tear
Struck submerged object or Grounding
Sinking
Engine failure
Collision
Other
Trailer Damage
Yes
No
Towing
Yes
No
Was anyone else's property damaged?
Yes
No
Was anyone injured?
Yes
No
Were there any witnesses?
Yes
No
Has a report been made by any governmental authority?
(Police, sheriff, DNR, Coast Guard, etc..)
Yes
No
Was anyone given a citation or ticket for any alleged violations?
Yes
No
Is your vessel operable?
Yes
No
Please describe the circumstances of the incident giving rise to the loss
U.S. COAST GUARD ACCIDENT REPORT: Please complete the following Recreational Boating Accident Report for submission to your state boating authority if your claim involves bodily injury or property damage of $2,000 or more and retain a copy in connection with your claim by clicking
here
I have completed the aforementioned U.S. Coast Guard Recreational Boating Accident Report
INSURANCE FRAUD: Any person who knowingly and with intent to defraud, deceive, or injure any insurance company, files a statement or claim containing any false, incomplete, or misleading information, or who conceals material information for the purpose of misleading any insurance company, has committed criminal insurance fraud.
I have read the foregoing insurance fraud statement