Notification of Marine Claim

  Type of Claim:  
  Name:  
 

Address:

  
  Policy Number:  
 

Policy Effective Date:

  
  E-mail:  
 

Agency:

  
 

Agent:

  
 

Residence Phone:

  
  Mobile Phone:  
 

Business Phone:

  
       
 

Marine Claim

  
       
       
  Type of Vessel:  
       
 

    Description of the event:

 

  
       
 

Estimate of damages:

  

Real Legacy Assurance Company, Inc.

P.O.Box 71467
San Juan, P.R.
00936-8567

Metro Office Park
Calle 1 Lote 4
Guaynabo, P.R. 00968

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