Marine Cargo Claim Form

1 of 2

Marine Cargo Claim Form, Hong Kong SAR. Published 09/2020.

and its respective logos, and

Chubb.Insured.

are protected trademarks of Chubb.

Marine Cargo

Claim Form

Claims Department

Chubb Insurance Hong Kong Limited

39/F, One Taikoo Place,

979 King's Road,

Quarry Bay, Hong Kong

O +852 3191 6800

F +852 2560 3565

E MarineClaims.HK@chubb.com

www.chubb.com/hk

Important Information:

1. This form should be completed as fully and accurately as possible and return to us immediately whether a claim has been made

on the Insured or not. If the space is not enough or no applicable field is available, please supplement information by attachment.

2. The list of documents required is not exhaustive and we reserve our right to request any additional information / documentation

from you, as necessary.

3. The submission on an incomplete form or insufficient information or supporting documents my delay the processing or result in

the denial of your claim.

Part I – General Information

Certificate Number:

Policy Number:

Claimant Name:

Role of Claimant:

□ Shipper □ Consignee

□ Others: ______________

Insured:

Contact Name:

Telephone:

Email Address:

Part II – Details of the Loss

Date of Arrival:

When was the loss discovered?

Nature of Loss:

□ Wet Damage □ Dent / Crushed / Tom □ Rust □ Missing / Non-Delivery

□ Leakage □ Shortage □ Others: ______________

Part III – Details of the Transit

Voyage:

(From)

(To)

On Board / Flight Date:

Vessel Name / Flight Number:

Types of Transport:

□ Road Carrier □ Rail □ Sea □ Air □ Courier

INCOTERMS:

□ CIF □ FOB □ CFR □ DDU □ Other: ______________

Part IV – Detailed Statement of Claim (if insufficient room, please attach a separate schedule)

Name & Product

Quantity

Unit Price

Amount Claimed

2 of 2

Marine Cargo Claim Form, Hong Kong SAR. Published 09/2020.

and its respective logos, and

Chubb.Insured.

are protected trademarks of Chubb.

Part V – Claim Payment Details (for fast payment of claims, please provide your bank account details)

Name of Bank:

Account Name:

Account Number:

Swift Code:

Bank Address:

Account Currency:

Part VI – Declaration & Authorization

I / We declare that to the best of my knowledge and belief the above statements and particulars contained are in all respects true and

complete and are made without reservation of any kind. A photocopy of this authorization shall be considered as effective and valid as the

original.

I / We further hereby declare and agree, that the personal information collected or held by Chubb Insurance Hong Kong Limited, whether

contained in this claim form or otherwise obtained, may be used by Chubb Insurance Hong Kong Limited or disclosed to any individual or

organization such as legal rms, accountants, actuaries, loss adjudicators and claims investigators, doctors and other medical service

provider within or outside Hong Kong SAR and as more particularly set out in the Chubb Privacy Information Collection Statement for the

following purposes: (1) to assess and process this application, (2) to provide insurance and customers services, (3) to conduct insurance

claims or analysis. I / We understand that if I / We do not provide such consent, or revoke my / our consent, Chubb Insurance Hong Kong

Limited may not be able to process or assess my / our claim. A copy of the Chubb Privacy Information Collection Statement can be found

at www.chubb.com/hk.

Any persons from whom Chubb Insurance Hong Kong Limited has collected information as aforesaid shall have the right of access to and

to request correction of any personal information concerning themselves held by Chubb Insurance Hong Kong Limited. A request for such

access may be made to the Personal Data Privacy Officer of Chubb Insurance Hong Kong Limited at 39/F, One Taikoo Place, 979 King's

Road, Quarry Bay, Hong Kong.

Signature of Insured & Company Chop:

Name of Insured (in BLOCK CAPITALS):

Date Signed:

Part VII – Required Documents

Please enclosed the following documents (if applicable):

1. Certificate of Insurance/ Insurance Policy

2. Bill of lading/ Air waybill

3. Commercial Invoice (with INCOTERMS between seller and buyer)

4. Packing list

5. Photos showing the damaged goods

6. Confirmation letter issued by forwarder (for non-delivery cargo only)