GENERAL CLAIM FORM

INSURED DETAILS

DETAILS OF DAMAGE OR LOSS

For Theft / Burglary

You must immediately inform the police if property has been lost or if you suspect burglary, theft, arson, malicious damage or any other criminal act that has caused the damage or loss. Please attach a copy of the Police acknowledgement form or note file number below

Property Schedule

Description of property lost Date bought or received
Present cost of replacement
(quotes required)
Amount claimed
Drop a file here or click to upload Choose File
Maximum upload size: 52MB
Download our schedule here: template file
Please attach proof of purchase/ownership on all items claimed. Proof of purchase can be but is not limited to one of the following: receipts, photographs, packaging, serial numbers, etc.
Please attach quotes for replacement of items claimed.
Drop a file here or click to upload Choose File
Maximum upload size: 52MB

PRIVACY ACT

Pursuant to the Privacy Act 1993 the following is brought to your attention:
(a) This claim form collects personal information about you;
(b) The information is collected to evaluate your claim;
(c) The intended recipient of the information is: The Insurer named below (hereinafter called "the Company")
being held by them at their head office
(d) The collection of this information is required pursuant to the terms of your insurance policy;
(e) the failure to provide this information may result in your claim being declined;
(f) You have rights of access to, and correction of this information, and is subject to the provisions of the Privacy Act 1993.

DECLARATION

1. I/We agree to The Company disclosing my/our personal information regarding this claim to:
(a) Other parties including other members of the Insurance Industry and the database of the Insurance Claims Register (ICR Ltd) PO Box 474, Wellington where it will be retained and made available to other insurance companies to inspect.
(b) Parties who have a financial interest in the subject matter of the policy and parties repairing or replacing the subject matter of the claim.
(c) I/We understand that I am/We are entitled to have certain rights of access to and correction of the personal information held by The Company and ICR Ltd.
2. I/We agree to The Company obtaining personal Information about me/us that is, In The Company's view, relevant to this claim.
(a) From any other party including other members of the Insurance Industry and from Insurance Claims Register Ltd (ICR Ltd) which holds details of claims made by me/us under policies with other Insurers.

All the information and answers (whether written or oral) given to The Company in connection with this claim are correct and that no information relevant to the claim has been omitted. I/We authorise The Company to act on my/our behalf.

By checking this box and submitting the form, you have agreed with all terms of this declaration.