Page 187 - claims information pack ebook_e

Example Claim Form Claim Number(s) (for internal use only)
PART 3
Declaration

Declaration

My claim is, to the best of my knowledge and belief, a true and accurate reflection of my actual
loss. It includes information on all financial or material gains I have received, including from
clean-up activities and aid organisations or government funds, during the period claimed.
I am aware that the shipowner’s insurer and the 1992 Fund takes the presentation of fraudulent
documentation seriously and if it/they becomes aware that such documentation has been
submitted in support of my claim, it/they reserves the right to inform the appropriate national
authority should that be the case.

Full name of claimant (printed):
42

Signature of claimant:

Claim number(s) (if known):

Notes:

● For partnerships (general partnerships and limited partnerships), all general partners must
sign this declaration.
● For companies with limited liability, the declaration must be signed by all members/managers
(unless it is managed by one member/manager).
● For corporations with a board of directors, the declaration must be signed by the chairman of
the board of directors.

● For corporations with directors and a supervisory board, the declaration must be signed by
the chairman of the supervisory board.

● For associations, cooperatives or other community of private law or public law, the declaration
must be signed by the president or any legal representative of the said corporation, duly
authorised to that effect.

By signing the declaration, claimants are deemed to have agreed to the disclosure of the
information contained within the claim form and any supporting evidence produced in support
to the relevant parties directly involved with the payment of compensation (including the
shipowner’s insurer, the 1992 Fund, its/their experts, and the Limitation Court.)