Page 159 - claims information pack ebook_e

Example Claim Form
PART 2 Section A Claim Number (for internal use only)
Costs of clean up and preventive measures
Section A

Summary of your claim
In addition to the information required under the checklist, please also provide the following information. Please
enter a summary of the requested information below. The boxes below can be expanded when completing
electronically. When completing by hand, separate sheets can be added if further space is required. However,
please provide detailed information in a spreadsheet.
1) A summary of events (description and justification of the work carried out at sea, in coastal waters and
on shore, together with an explanation of why the various working methods were selected).

2) Details of the area(s) where the clean-up operations and preventive measures were undertaken. Please
provide a marked map/chart and photographs (if available) indicating the location of the clean-up operations
conducted.

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3) Date(s) on which such clean-up operations and preventive measures took place.

4) A detailed description of the clean-up operations conducted and preventive measures undertaken.

5) Details of the personnel used for the operations, including:

a. Number and roles of personnel employed;

b. Days/hours worked, daily/hourly rate and overtime rate (specify calculation method, other labour costs, etc.);

c. Travel and accommodation expenses for response personnel;

d. Summary of costs of food, personal protective equipment, communications, etc. for response personnel.

6) Details of the equipment used for the operations. Please provide full details on a spreadsheet and send with
your claim form. Please also provide information on how and where the equipment was used together with
full technical specifications (equipment manufacturer, capacity, etc.).