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CLAIM NOTE

Messrs. MITSUI SUMITOMO INSURANCE CO., LTD. 　　　 Date

Dear Sirs,

We are sending you herewith our claim note for the undermentioned with the request that you will be kind enough to make settlement of the claim at the earliest date, and oblige.

　　Yours faithfully,

Signature:

Name :      

Title :      

Company :      

Policy No.      

Conveyance      

Sailed from       on      

Arrived at       on      

Cargo 　      

Casualty      

CALCULATION

Claim Amount　　     

Please arrange remittance for the above amount to the following account.

|Payee’s Name | |

|Bank Name | |

|Branch | |

|Account No. | |

|SWIFT Code | |

|IBAN Code | |

|Bank Location |City : |Country : |

|Payee's Residence |City : |Country : |

-----------------------

I hereby acknowledge that the Mitsui Sumitomo Insurance Company Limited ("MSI") may obtain and/or utilize my personal information related to this insurance claim for the [?]0246:Xv²´¾ÀÔÖä\ b p ëÜÑÅÑܯܣ•‡y•kb]M•y•purposes of performing MSI's obligations under the insurance policy and/or offering or providing other products or services of MSI, and authorize MSI to provide the information to a third party(ies) in the manner(s) described below;

1. To any party(ies) involved in the insured casualty (including without limitation repairers, medical facilities, carriers of insurance or other similar instruments or arrangements, and mutual aid associations), any agents of MSI (including without limitation MSI's insurance agencies), or any other party(ies) as may be necessary in performing MSI's obligations under the insurance policy, including without limitation that of loss survey, liability determination, loss adjustment, and/or underwriting.

2. To any reinsurance company(ies) and/or broker(s) for the purpose of negotiating or executing a reinsurance contract, performing an obigation(s) and/or exercising a right(s) pursuant to the terms and conditions of a reinsurance contract.

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