Page 185 - claims information pack ebook_e
P. 185
Example Claim Form
PART 2 Section E Claim Number (for internal use only)
Other Losses
Section E
7) Costs of storage or disposal of oil and oily products recovered (specify quantity of waste
and disposal method)
8) Total of other costs or expenses incurred
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 you have used to calculate the total
40 amount of the claim.
Item 5: Cost of personnel (5b+5c+5d) +
Item 6(A): Net cost of equipment owned +
Item 6(B): Cost of equipment rented +
Item 6(C): Cost of equipment purchased +
Item 7: Cost of storage/disposal of oil or oily products +
Item 8: Other costs/expenses +
Total =
Additional Information:
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.
Please submit all original supporting documents and evidence for all costs incurred as detailed above.
