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To Ethiopian Insurance Corporation at

Please survey the goods described below, and issue your Certificate to me/us, on
delivery of which I/we undertake to pay the charges specified therein.

Description of Goods :-

Marks and Numbers:-

Branch claim to be submitted.
  Ex Vessel “ ; Discharged on the Day of
And delivered into my/our custody on the Day of
Number of Packages/Units to be examined:-
Damaged Packages, which have been separated from the sound, can be seen at (state exact
Locality) Where they are awaiting your inspection.
(*) Notice of damage/loss was given to the Agents of the Vessel “ ;
On the
(*) Notice of damage/loss addressed to the Agents or Owners of the Vessel “ ;
Is attached to this application and I/we request you to forward this on my/or behalf to the
proper party, whose reply will be forwarded to you in due course for notation on the
Certificate of Survey.
Signature(Full Name) of Applicant :-
Address :-
Telephone :-


It is the duty of the Assured and their agents, in all cases, to take such measures as may
be reasonable for the purpose of averting or minimizing a loss and to ensure that all rights
against Carriers, Bailees or other third parties are properly preserved and exercised. In
particular, the Assured or their Agents are required:-

  1. To claim immediately on the Carriers, Port Authorities or other Bailees for any
missing packages.
  2. To apply immediately for survey by Carriers or other Bailees Representatives if
any loss or damage be apparent and claim on the Carriers or other Bailees for
any actual loss or damage found at such survey.
  3. In no circumstance, except under written protest, to give clean receipts where
goods are in doubtful condition.
  4. To give notice in writing to the Carriers or other Bailees within 3 days of
delivery if the loss or damage was not apparent at the time of taking delivery.
NOTE:- The Consignees or their Agents are recommended to make themselves familiar with
the Regulations of the Port Authorities at the port of discharge.

To enable claims to be dealt with promptly, the Assured or their
Agents are advised to submit all available supporting documents without
delay, including when applicable:-

  1. Original policy or certificate of Insurance.
  2. Original or copy shipping invoices, together with shipping
specification and/or weight notes.
  3. Original Bill of Lading and/or other contract of carriage.
  4. Survey report or other documentary evidence to show the extent of
the loss or damage.
  5. Landing account and weight notes at a final destination.
  6. Correspondence exchanged with the Carriers and other parties
regarding their liability for the loss or damage.
  To the Owners or Agents at Of the Vessel “  
  Goods :
  Marks and Numbers:
* Here Insert If
particulars of the
quantity of goods
damaged or lost.
If the quantity if
not definitely
known say “a
part; or a
quantity or some
such general term
  I/We have to inform you that of the above goods deliverable to me/us ex the
On (date) are found to be damaged/lost
and I/we beg to notify you that I/we hold Owners of the vessel as Carriers responsible for
this damage/loss.
The goods delivered are at present lying at Where they will be surveyed
by Ethiopian Insurance Corp. or their Agents on th e And you are
Invited to attend the survey. Please acknowledge receipt of this notice on the form attached
Signed (Full Name):
  I/We have to acknowledge receipt of your Notice of damage/loss in respect of
the above shipment and to inform you that
Singed (Full Name):