Marine Self Survey Report

Claim No.
Consignor
Consignee
POLICY DETAILS
Policy No / Certificate No:
Insured:
Policy Period/Date of
commencement of
Voyage/transit:
Place of origin & final
destination
Subject Matter Insured:
Sum Insured:
asis of Valuation
Declaration:
Date of !oss:
Place & circumstances of t"e
loss
Date of Intimation to Insurer
##/!#/!/$% No. Date:
Name of t"e Carrier
Cause / Nature of !oss
Descri&tion of Pac'ing
Su&&orting Documents:
Amount of Loss:
Loss Assessment:
Descri&tion (uantity #ate )In #s.*
$mount
)In #s.*
$ssessed !oss:
$dd +,-: )If $&&licable*
Sub Total:
De&reciation: )If $&&licable*
Sal.age:
/0cess:
1otal !oss Payable )#ounded
2ff*:
Total Loss Amount Payable:
Claim Reommen!ation
T"us loo#in$ to%ar!s all t"e above fats an! base! on papers net laim payable is
Rs& '()**&(+',-&