Theft Claim Form

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Theft Claim Form
Policy Holder/Vessel:
Name/Company:
Address:
Phone:
Fax:
Mobile No.:
Policy No.:
E-mail:
Customer No.:
Are you able to recover VAT with regard to this claim? Name of the Yacht:
Build or CIN/HIN No.:
Yes
No
Model:
Year of construction:
In order to process the afore mentioned claim in a quick and uncomplicated fashion and to avoid unnecessary questions
from the insurers, please provide us with truthful and detailed information to the following questions:
Date of claim:
Where was the boat lying at the time of the theft?
Please draw a sketch of the scene of the crime, include your boat’s berth as well as inhabited buildings in the
area. (if needed, sketch on an additional sheet please).
[email protected] · pantaenius.es
*Registrada en la Dirección General de Seguros y Fondos de Pensiones (DGSFP), clave AS-64. R.C. contratada con AXA Versicherung AG.
**Pantaenius America Ltd. is a licensed insurance agent licensed in all 50 states. It is an independent corporation incorporated under the laws of New York and is a separate and distinct entity from any entity of the Pantaenius Group.
ESP12269
Germany · Great Britain · Monaco · Denmark · Austria · Spain* · Sweden · USA** · Australia
Pantaenius Spain S.L. · c/. Torre de Pelaires, 5 · 07015 Palma de Mallorca ·Tel. +34 971 70 86 70 · Fax +34 971 70 86 71
www.hqhh.de 01/2014 en
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Theft Claim Form
How is the area protected against the entry of unauthorized persons?
How is the access to your boat and the boat itself protected against theft?
How did the thieves attain the stolen goods?
Who last checked the condition of your yacht?
When?
Who noticed the theft?
When?
Yes
Did a responsible authority produce a report?
No
If yes, please include the name, address and reference number and if possible a copy of the report.
daily How often is the boat checked? several times a week irregularly
Witnesses (Name/Address/Phone/E-mail):
Please provide their signed declaration attached with a copy of the identity card.
[email protected] · pantaenius.es
*Registrada en la Dirección General de Seguros y Fondos de Pensiones (DGSFP), clave AS-64. R.C. contratada con AXA Versicherung AG.
**Pantaenius America Ltd. is a licensed insurance agent licensed in all 50 states. It is an independent corporation incorporated under the laws of New York and is a separate and distinct entity from any entity of the Pantaenius Group.
ESP12269
Germany · Great Britain · Monaco · Denmark · Austria · Spain* · Sweden · USA** · Australia
Pantaenius Spain S.L. · c/. Torre de Pelaires, 5 · 07015 Palma de Mallorca ·Tel. +34 971 70 86 70 · Fax +34 971 70 86 71
www.hqhh.de 01/2014 en
continue page 3
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Theft Claim Form
List of stolen goods:
Please enclose all available invoices for the items noted:
N°
Name
Make + Type
Purchase Year
Purchase Price
Current price
What other damage was incurred as a direct result of this theft?
Important
Please provide an estimate; no repairs are to be undertaken without our approval. The insurers must be able to
verify the nature, extent, causes and cost of repair of the damage to the vessel except when the insurers specifically
renounce this prerogative.Take note of § 11 of Pantaenius Yacht Hull Clauses (PYHC) concerning obligations of the
insured case of an insured claim event and the consequences of the non-respect of those obligations.
Mandatory Documents for the Handling of Your Claim
Please provide us with copies of:
- Ownership’s Act (Registration documents or equivalent document depending on flag).
- ID of the Owner and the Insured.
For a company please also provide for the settlement, all documents should not be older than three months:
- A trade register certificate mentioning the name of the person entitled to sign the Subrogation Act.
- ID Card of this person.
- An original document, certified by a notary or a lawyer, that the signatory is entitled to sign the Subrogation Act for settlements
exceeding 5.000 €
N.B: Settlement in favor of companies will be net of taxes, unless formal proof, such as an official statement from a CPA, is given that
the company is not able to recover VAT in this claim.
I agree when submitting the claim to Pantaenius, that my personal data will be saved and made available to insurers, surveyors,
law firms and other authorities etc. in so far Pantaenius deems this necessary in order to handle the claim. After closure of
the claim, my data will be saved according to the data protection law currently in force.
WE ADVISE YOU THAT CONSCIOUS FALSE OR INCOMPLETE STATEMENTS AND/OR
INFORMATION COULD ALSO LEAD TO THE INSURERS BEING RELEASED FROM THEIR OBLIGATION
OF INDEMNIFICATION, EVEN IF NO DISADVANTAGES THEREBY ARISE FOR THE INSURERS.
I hereby attest to the accuracy of the afore mentioned declaration
Policy Holder’s Signature:
Germany · Great Britain · Monaco · Denmark · Austria · Spain* · Sweden · USA** · Australia
Pantaenius Spain S.L. · c/. Torre de Pelaires, 5 · 07015 Palma de Mallorca ·Tel. +34 971 70 86 70 · Fax +34 971 70 86 71
[email protected] · pantaenius.es
*Registrada en la Dirección General de Seguros y Fondos de Pensiones (DGSFP), clave AS-64. R.C. contratada con AXA Versicherung AG.
**Pantaenius America Ltd. is a licensed insurance agent licensed in all 50 states. It is an independent corporation incorporated under the laws of New York and is a separate and distinct entity from any entity of the Pantaenius Group.
www.hqhh.de 01/2014 en
ESP12269
Date/Place: