MOTOR VEHICLE CLAIM FORM

To be completed even if parked
Passenger 1
Passenger 2
Witness 2
Owner & Vehicle / Property 1
Owner & Vehicle / Property 2
NOTE! Do not proceed with repairs without the Company's authority

SKETCH A PLAN OF THE ACCIDENT


(example sketch goes here)
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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.
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.