A. General Information
Insured Name Policy Number
Address
Contact Name
Telephone – Home Business Mobile
Email Address
B. Details of the Loss
Date of loss: When was the loss discovered?
Brief description (includes cause of loss or damage):
Where did the Event occur?
C. Details of the Transit
Journey from To Date
Carrier’s name and contact
Type of transport
Own Vehicle
Road Carrier
Rail
Post
Sea
Air
D. Details of the Goods
Are you the owner of the goods?
Yes
No
If ‘NO’, please provide details of the owner
Did any other insurance cover the goods at the time of loss?
Yes
No
If ‘YES’, please provide the particulars and name of the insurer
If goods are damaged where can they be inspected? (Please advise contact name and phone number)
Have Police been notied?
Yes
No
If ‘YES’, what station? Incident Number Date
Have you taken any other action to reduce your loss?
Yes
No
If ‘YES’, please provide details
Page 1 of 4
Marine Claim Form
Please return this form together with attachments to aus.marineclaims@chubb.com
Page 2 of 4
E. Detailed Statement of Claim (if insucient room, please attach a separate schedule)
Full Description of item
(e.g. make, model, age)
Details of loss or damage Sum Insured Amount claimed
F. GST Supplement
Are you registered for GST purposes?
Yes
No
ABN
What is your Tax Credit Extent (Percentage)?
G. Claim Payment Details (for fast payment of claims, please provide your bank account details)
Name of bank
Account Name
BSB: Account number
For international payment, please provide the Bank Swift Code
Bank Address
If paying into an overseas bank, what currency is the account in? (e.g. USD)
H. Supporting Documentation (the following documents are required in support of the claim)
Letter of claim on carrier/ship/airline
Invoice showing value of goods claimed
Consignment note/Bill of lading/Airway bill
Response (if any) from carrier/ship/airline
Repair/Replacement quotations (if applicable)
Freight Invoice
If any of the above are not available, please advise why
Page 3 of 4
By clicking on Submit, a new email will open automatically with your completed form attached.
Please attach any supporting documentation to the email and send to aus.marineclaims@chubb.com
Chubb Insurance Australia Limited, Claim Privacy Consent and Declaration
Claim Privacy Consent
Chubb Insurance Australia Limited (Chubb) collects, uses and handles your personal information in accordance with the Privacy Act 1988 (Cth).
You can access a copy of our Privacy Policy on our website at https://www2.chubb.com/au-en/footer/privacy.aspx or by contacting our customer
relations team.
Your personal information will be used by Chubb, or third parties engaged by Chubb, for the purpose of assessing your claim or your entitlement
to benets and, if the claim is accepted, for administration of the claim and for planning, product development and research purposes including
customer surveys.
In so far as it is relevant to the claim, your personal information may include:
a) information that is health information or sensitive information, including, without limitation, your medical history, any treatment received by
you and any medication taken or prescribed for you (at any time) or your health insurance claims history, including Medicare;
b) information relating to other insurance policies, including terms and conditions and claims history;
c) details of your employment including position, period of employment, remuneration, hours worked and duties performed (at any time);
d) information relating to your income, assets, liabilities and solvency;
e) information from third persons who may have information relevant to your eligibility to receive a benet, or your entitlement to receive an
ongoing benet;
f ) payment or billing information, such as bank account details, direct debit and credit card details or premium funding and insurance payment
arrangements; and
g) any other personal information that you may provide to Chubb or its third party contractors.
Collection from and Disclosure to Third Parties
To assess and process your claim Chubb may need to collect your personal information from third parties such as, but not limited to, your insurance
broker, claims reference services, government organisations (for example, social security agencies or taxation oces), your doctor or other health
service provider, any forensic accountant or investigator retained by Chubb, your employers (past and present), your accountant and any businesses
which provide information about the commercial activities of persons or, if you are, or have been, bankrupt the trustee of your estate.
Chubb may disclose your personal information, including health and sensitive information, to other entities within the Chubb Group, other
insurers, our reinsurers or third parties, including contractors and contracted service providers (such as assessors or investigators) who we, or
those other Chubb Group entities, have engaged to provide a specic service related to the administration of your claim and the policy. Those
entities may be located overseas, for example the regional head oces of Chubb in Singapore, UK or USA or third parties with whom we or those
other Chubb Group entities have subcontracted to provide a specic service for us, which may be located outside of Australia (such as in the
Philippines or USA). These entities and their locations may change from time to time. Please contact us, if you would like a full list of the countries
in which these third parties are located.
Chubb may also disclose your personal information to witnesses in respect to your claim and to government agencies including the police (where
we are compelled to by law).
If you’d like a copy of your personal information or wish to correct or update it, want to withdraw your consent to receiving oers of products
of services from us or persons we have an association with, please complete Our Personal Information Request Form online or download it from
www2.chubb.com/au-en/footer/privacy.aspx and return to CustomerService.AUNZ@chubb.com or contact our customer relations team
on 1800 815 675.
Please note if you do not consent to the terms of this Privacy Consent or revoke your consent, Chubb may not be able to process or assess your claim.
Privacy Consent, Declaration and Authority
I:
• consent to the collection, use and disclosure of my personal information in accordance with Chubb’s Privacy Policy and this document for the
assessment of my claim. This consent remains valid unless I alter or revoke it by giving written notice to Chubb as outlined above;
• understand that by investigating my claim or by accepting proof of my claim, Chubb has made no acceptance of liability, nor waived any of its
rights in defense of any claim arising under the insurance policy;
• agree to use my best endeavors and render all reasonable assistance and co-operation to Chubb in the assessment of my claim;
• conrm that any information that I supply will be true and correct and that I will not withhold any information likely to aect the acceptance
or handling of my claim;
• understand that my claim may be denied if the information supplied is untrue, or I have not revealed all relevant facts;
• authorise any person or entity, including but not limited to the third parties referred to above, to provide to Chubb such personal information
as Chubb considers relevant for its assessment of my claim;
• authorise Chubb to disclose my personal information (including sensitive/health information) to other third parties referred to above (who
may be located overseas) where relevant to the assessment of my claim;
• appoint Chubb to do everything necessary including to execute on my behalf any documents or do such acts as required to give eect to this
Privacy Consent, Declaration and Authority.
Signature of Claimant
Name of Claimant Date
Submit
Page 4 of 4
About Chubb in Australia
Chubb is the world’s largest publicly traded property and casualty insurer. With operations in 54 countries and territories, Chubb
provides commercial and personal property and casualty insurance, personal accident and supplemental health insurance,
reinsurance and life insurance to a diverse group of clients. As an underwriting company, we assess, assume and manage risk with
insight and discipline. We service and pay our claims fairly and promptly. The company is also dened by its extensive product
and service oerings, broad distribution capabilities, exceptional nancial strength and local operations globally. Parent company
Chubb Limited is listed on the New York Stock Exchange (NYSE: CB) and is a component of the S&P 500 index. Chubb maintains
executive oces in Zurich, New York, London, Paris and other locations, and employs more than 30,000 people worldwide.
Chubb, via acquisitions by its predecessor companies, has been present in Australia for 100 years. Its operation in Australia (Chubb
Insurance Australia Limited) provides specialised and customised coverages, including Business Package, Marine, Property,
Liability, Enery, Professional Indemnity, Directors & Ocers, Financial Lines, Utilities, as well as Accident & Health insurance, to
a broad client base, including many of the country’s largest companies. Chubb also serves successful individuals with substantial
assets to protect and individuals purchasing travel and personal accident insurance. With ve branches and more than 800 sta in
Australia, it has a wealth of local expertise backed by its global reach and breadth of resources.
More information can be found at www.chubb.com/au.
Contact Us
Chubb Insurance Australia Limited
ABN: 23 001 642 020 AFSL: 239687
Grosvenor Place
Level 38, 225 George Street
Sydney NSW 2000
O +61 2 9335 3200
F +61 2 9335 3411
www.chubb.com/au
Insurance cover is issued by Chubb Insurance Australia Limited, ABN 23 001 642 020, AFS Licence Number 239687. This form is for information collection purposes only,
contains general information and may not suit your particular circumstances. The precise insurance cover provided is subject to the terms, conditions and exclusions set out
in the relevant Product Disclosure Statement (PDS) or General Product Information (GPI) and the insurance policy when issued. Insurance cover may not apply to the extent
that trade or economic sanctions or other laws or regulations prohibit Chubb, its parent company or its ultimate controlling entity from providing insurance cover. Chubb is
authorised to provide general insurance products. Please obtain and read carefully the relevant insurance policy before deciding to acquire any insurance product. A Policy
wording can be obtained at www.chubb.com/au; through your broker or by contacting any of the Chubb oces. Marine Claim Form, Australia. Published 09/2019.
©2019 Chubb Insurance Australia Limited. Chubb®, its logos, and Chubb.Insured.
SM
are protected trademarks of Chubb. Chubb06230919
