To:

NAME OF SHIP: ____________ HULL NO.: ___________ CONSECUTIVE NO.: __________ DATE: ___________

This report concerns damage, breakdown or deficiency which can be claimed against builder, and the form shall be sent to the company on the first opportunity by the master.
WHEN & WHERE FIRST DISCOVERED:
SHORT DESCRIPTION OF FAILURE (EVENTUALLY WITH A SKETCH OR PHOTO ATTACHED):
MASTER/CHIEF ENGINEER'S OPINION: REPAIR RENEW MODIFY ADJUST
WORK PERFORMED BY: NAME: ___________________ POSITION: ________________
WORK PERFORMED ONBOARD:
CONSUMPTION OF SPAIR PARTS: DEFECTIVE ARTICLES ONBOARD: YES NO REPAIR/SUPPLY TO BE EFFECTED: IMMEDIATELY CONVENIENCE PORT GUARANTEE DOCKING PARTS NO. AND DESCRIPTION: NAME & ADDRESS OF MAKER:
MASTER	CHIEF ENGINEER			CHIEF OFFICER			CLASS SURVEYOR OR CONSULTING ENGINEER/OR GUARANTEE ENGINEER
CHIPOBROK OFFICE			FOR BUILDER:					DATE:
JUDGEMENT / ADVICE OF TECHNICAL DIVISION.
					________________________________ SIGNATURE
FOLLOW-UP

Note: To be completed by case and filed in both office's file and ship's file.

To retain for 5 years.

Issue date: 03.11.2003/Rev. 00 P-G∗02-F03 Page: 1/1

STATEMENT OF GUARANTEE CLAIM

QSMS P-G∗02-F03 Rev. No.00

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