Marine Protest by Ship Captain

Republic of the Philippines)
Province of ____________________) S.S.
City/Municipality of _____________)
x – – – – – – – – – – – – – – x


Name: ______________ Age: _____Civil Status: _______
Address: _________________________________
Position: __________________Type/Cargo: ___________
Home Port: ___________________________________
Registry Number: ___________________________
Burden/Cargo: _____________________________
Gross Tons:_____________ Net Tons: ____________

After being duly sworn to in accordance with law, do hereby declared and state on protest. That on (continue with facts and circumstances that transpired in the______________________incident)

That I, as Master, (Indicate what actions the master initiated _________________________.

That I as Master (Indicate the respondents and their address if any.)____________________________________.

That I as Master (Indicate the respondents and their address if any.) _________________________________.

That the prevailing weather at the time was as follows:

General Description: ______________________
Wind Direction: _______Velocity: ____ Kits: _________
Height of Seas: _________Feet: ____________
Tide: __________________ Flood ____________
Visibility: ___________________________
Other Remarks: _____________________

That the incident resulted injuries to ___________________ persons and death to _____________ persons, whose names are listed in Exhibit “A” of this PROTEST

That this incident likewise resulted to loss or slight damage to the _____________ belonging to _____________ in the estimated amount of ______________________________ (P____________) and detailed in Exhibit “B” of this PROTEST:

That my organization / shipping company is as follows:

Address: __________________________
Telephone(s) _______________________
Fax: ______________________________

That further/additional information/data is appended hereto as Exhibit “1” of this PROTEST.