Claims Causation Reporting Form - Injury/Illness/Death

PRIVILEGED AND CONFIDENTIAL: IN CONTEMPLATION OF LITIGATION

Vessel Name Country Nationality of Crew Involved

Club File Reference Port Weather Condition

Name of Party 3rd Party/Crew/Passenger

Additional Notes

Age

Nationality

Resulted in death

Work related

Location of the incident

Repatriation/
Deviation required

Injury

Nature of injury

Cause due to defective

machinery e.g. bad
work practices

Illness

Nature of illness

Pre-existing illness

Drug and alcohol related

Surveyor’s opinion
PEME (carried out) of primary cause*

Statement of facts
included in report *Primary Cause: 1. 3rd Party Negligence 5. Inadequate procedures/guidance
2. Act of God 6. Insufficient training
Crew’s certificates 3. Human factor 7. Personal illness
valid and appropriate 4. Inadequate ship maintenance 8. Shore-based management
for ship trade

www.shipownersclub.com This summary report is not a substitution for a full indepth report. However, it does form part of the survey report and therefore has the same status. Claims Causation Reporting Form - Injury/Illness/Death