Claims Loss Report | Admiralty Insurance

Submit the following information to us so we can notify the insurance company of the details of the loss. Remember this is a web tool designed to expedite the claims process.

All fields should be completed. If a field does not apply insert “NONE”.

Policy Holder Information

Name of Person Reporting Claim
Name of Insured
Policy Number
Address
City
State
Zip Code
Phone
Alternate Phone
Fax Number
Email Address
Next 1 / 3

Loss Details

Date of Loss
Time of LossHHMMAM/PM
Location of Loss including City, State, Marina or Body of Water
Description of the Loss and Damage
Name of Police or Coast Guard Where Report Was Filed:
Estimated Amount of Loss
Name(s) of Witness(es):
Names of other persons or boats involved
Names, injuries and contact information of other persons involved
Present Location of the Vessel
Next 2 / 3

Repair Vendor

Name
Address
Phone Number
Contact Person

Verification

Please enter any two digits with no spaces (Example: 12) *
This box is for spam protection - please leave it blank:

3 / 3