Boat/Yacht Loss Report - West Coast Marine Insurance

Please complete this form to report any boating claim direct to our office. In order to save time in processing the claim, this form must be emailed or faxed to our office. If you have any questions, call (800) 424-2628. Fax#: (800) 590-2080.

Loss Report

* Insured's First Name:

* Insured's Last name:

* Address:

* City:

* State:

* Zip:

* Home Phone:

* Work Phone:

* Fax:

* Email:

* I prefer to be contacted by:

Phone Fax Email Mail

*Date of Loss:

*Vessel Description:

*Location of Loss:

*Description of Loss:

Repair Shop Information

* Damage to Vessel:

* Repair Estimate Cost:

* Repair Shop Name:

* Repair Shop, Address:

* City:

* State:

* Zip:

* Repair Shop Phone:

* Repair Shop Fax:

Property Damage to Others

* Vessel's Description:

* Describe damage to Vessel:

* Owners First Name:

* Owners Last Name:

* Address:

* City:

* State:

* Zip:

* Home Phone:

* Work Phone:

Injured Persons

* Names:

* Address:

* City:

* State:

* Zip:

* Home Phone:

* Work Phone:

Operator or Passenger of Insured Vessel: Yes, No

* Date of Loss:

* Loss Reported by:

* Additional Information on Loss: