1. Marine Cargo claim form
AXA Insurance Gulf B.S.C.
Building 7, Dubai Outsource Zone, Manama Street
P.O. BOX 32505, Dubai – United Arab Emirates
(Clients) / (Brokers)
+971 (0)
Marine Cargo claim form
This claim form is not an admission of liability. We thank you in advance for filling in this claim form in full in order to assure a fast and accurate processing.
A. ADMINISTRATIVE
Policy No:
Claimant:
Address:
Phone No:
Physical Address:
B. DETAILS OF THE LOSS/DAMAGE
Date of loss / damage or knowledge of loss:
No. of packages:
Total weight:
Description of the goods :
Place of Loss:
Date of transit:
Details of Consignor/Consignee (if different from Claimant)
Circumstances of loss or damage:
Was the incident reported to the Police? N Y N A
(please attach the Police report)
C. DETAILS OF THE CARRIER
How and by whom were the goods transported?
Have you advised them of the loss or damage? Y N
Date you have advised:
(please attach a copy of the notice of the claim to the carrier)
D. PARTICULARS OF GOODS LOST OR DAMAGED
Estimated value of the damaged goods:
Address and contact details where damaged goods can be inspected:
E. POLICYHOLDER DECLARATION
I/We hereby declare that the above mentioned particulars are true to the best of my/our knowledge and beliefs.
Date: Signature:
If you have any question regarding this form or any other aspect of the cover, please send you enquiry to our Non Motor Claims Team at the address or by phone on (Clients) / (Brokers) by quoting your policy number. For a quick registration you can start submitting the form in a digital format by clicking on the button “--> Submit form”. Don’t forget to attach a digital copy of all supporting documents to the self-generated mail before sending the message to the address Following to the digital submission, this form must be signed and the original claim form mailed to AXA office address mentioned in the head of this claim form, along with any original documents required by AXA.
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