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REPORT A CLAIM
 
 
Insured information
Name
Mailing address
City
State
Zip code
E-mail Address
Home Phone #
Cell Phone #
Work Phone #
Alt Phone #
 
Your relationship to insured
 
Operator at time of loss (if applicable)
 
Claim information
Policy #
Year, make and model
Hull ID
Date of loss /
Time of Loss
Loss Location
 
Damage or loss caused by







 
Trailer Damage
Towing
Was anyone else's property damaged?
Was anyone injured?
Were there any witnesses?
Has a report been made by any governmental authority?
(Police, sheriff, DNR, Coast Guard, etc..)
Was anyone given a citation or ticket for any alleged violations?
Is your vessel operable?
 
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