GRIPSHOLM SHIPPING S.A.

SHIP MANAGEMENT

NOTICE OF DAMAGE BY STEVEDORE :

to SHIP ___________

or to CARGO __________
(Fill with a X where necessary)

From : __________________________ (master)

M/V

To :

Voyage No. ______________________________

__________________________ (stevedore)

______________________________

Port of

______________________________

Date

______________________________

You are hereby notified that we hold you responsible for the following damage, which occurred on the above ship as a result of
your stevedoring operations. The cost of replacement and/or repair will be for your account.
Date and time of damage :

______________________________________________________________________________

Description of damage

Cause of damage

___________________________(master)
___________________________(witness)
Signature and title
The cause and extent of the damage is correctly stated above

___________________________
(Stevedore representative)

(If damage is extensive and an agreement as to its exact nature cannot be reached on the spot, a survey should be called and
findings recorded below.)
I have surveyed the above damage to the above ship and report my findings as follows :
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
___________________________ (surveyor)
Date : ___________________________

1 Copy - Stevedore ; 1 Copy - Charterers ; 1 Copy - SUB Charterers ; 1 Copy - Ships Agent ;
1 Copy - GRIPSHOLM SHIPPING S.A. ; 1 Copy - Ships File No. 5

GRIP FORM - 05