Class of Bussiness*	Motor Marine Property Mics
Name of Financial Organization (If any)/Participant*
Policy #*
Date & Time of Loss*
Place of Loss*
Nature of Loss *	ACCIDENTAL DEATH AIRCRAFT ASSEMBLY FAULTS ATMOSPHERIC DISTURBANCE BAD WORKMANSHIP BURGLARY CARELESSNESS COLLISION AND OVERTURNING CONSTRUCTIVE TOTAL LOSS CONTAINER LIABILITY CONTAINER PHYSICAL DAMAGE AND LIABILITY CORROSIVE GASES DACOITY/ARMED HOLDUP DAMAGES / BREAKAGES DEFECTS IN CASTING AND MATERIAL DESIGN FAULTS EARTHQUAKE AND LANDSLIDE EARTHQUAKE FIRE AND SHOCK EARTHQUAKE SHOCK ELECTRICAL CLAUSE 'A' ELECTRICAL CLAUSE 'B' EXPLOSION FAILLING AIRCRAFT FALLING FAULTY OPERATION FIRE AND LIGHTNING FIRE AND LIGHTNING GENERAL AVERAGE IMPACT DAMAGE INCORRECT SUPERVISION LACK OF SKILL LEAKAGE LIGHTNING AND EXPLOSION MALICIOUS DAMAGE MANUFACTURING FAULTS MARINE LIABILITY OBSTRUCTION OR ENTRY OF FOREIGN BODIES OWN DAMAGE PERMANENT DISABLEMENT PHYSICAL EXPLOSION REMOVAL OF DEBRIS RIOT AND STRIKE DAMAGE SHORTAGE SHORTAGE OF WATER IN BOILER SHORT-CIRCUIT AND OTHER ELECTRICAL CAUSE SMOKE SNATCH SNATCHING SOOT STORM STORM AND FLOODING SUBSIDENCE TEMPORARY PARTIAL DISABLEMENT TEMPORARY TOTAL DISABLEMENT THEFT THEFT AND RECOVERED THEFT OF ACCESORIES THEFT/STOLEN THIRD PARTY BODILY INJURY THIRD PARTY DEATH THIRD PARTY PROPERTY DAMAGE THIRD PARTY VEHICLE DAMAGE WATER AND HUMIDITY WORKSHOP ERRORS
Name of Contact Person, Address & Contact # *
Registration #*
Engine # *
Chassis #*
Where vehicle can be inspected *
State Name & Address/Contact # of your usual repairers*
Estimated Amount of Loss

If third party has been injured or Damage has been caused to the vehicle or other property of third party, please answer the following additional questions: