Page 161 - 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

8) Costs of storage or disposal of oil, oily waste and oily products recovered (specify quantity of waste
and disposal method)

9) Total of other costs or expenses incurred eg. aircraft hire, vessel hire, treatment of waste, establishment of
wildlife treatment centre, removal of oil from the wreck, etc.

Calculation of the total amount of the claim
You may wish to use the following table as an example of how to calculate the total amount of the claim. Whichever
method you use, you must provide an explanation of the method used to calculate the total amount of the claim.

Item 5: Cost of personnel (5b+5c+5d) +
16
Item 6(A): Net cost of equipment owned +
Item 6(B): Cost of equipment rented +

Item 6(C): Cost of equipment purchased +
Item 7: Equipment repair costs +
Item 8: Cost of storage/disposal of oil or oily
+
products
Item 9: Other costs/expenses +
Total =

Additional Information
Are the expenses referred to in this claim insured in whole or in part? Yes No
If YES, please provide full details (name of insurance company, policy type, claim submitted, amount paid,
amount insured, any exclusions, etc.)

Provide details of any other claims for compensation you have made in connection with this incident.

Provide details of any other compensation or form of income you have received (e.g. state or regional
emergency funds, charitable donations, etc.) or you will receive in connection with this incident (name of
payer, amount received, etc.). If none, state NONE.

Have you submitted additional pages/documents to this claim form? Yes No
Please specify

Please submit all supporting documents and evidence for all costs incurred as detailed above