NON-MOTOR INTIMATION

FILL AND SUBMIT THE BELLOW FORM

Policy No / NIC No of the Individual / Business Registration No (BR No) if a company *

Policy Holder Name (Owner’s Name) *

Caller’s Name *

Caller’s Alternative Contact No *

Customer Email Address *

Description of the Loss *

Place of the Loss *

Incident Date *

Incident Time *

Hours

Minutes

Intimation Date *

Intimation Time *

Hours

Minutes

Intimated by *

Policy No / NIC No *

Policy Holder Name (Owner’s Name) *

Boat Number

Caller’s Name *

Caller’s Alternative Contact No *

Customer Email Address *

Description of the Loss *

Place of the Loss *

Cause of Loss *

Damages *

Nearest Town *

How many KM's to the land from the sea *

Multi Day Boat/Single Day BoatSingle Day BoatMulti Day Boat

Incident Date *

Incident Time *

Hours

Minutes

Intimated by *

Intimation Date *

Intimation Time *

Hours

Minutes

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