Stolen (Not Recovered) or Burnt Vehicle Claim Form

STOLEN (NOT RECOVERED) OR BURNT VEHICLE CLAIM FORM

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Maximum upload size: 52.43MB
Drop a file here or click to upload Choose File
Maximum upload size: 52.43MB
Drop a file here or click to upload Choose File
Maximum upload size: 52.43MB

PRIVACY ACT

WARNING: If you supply any untrue or false information and know that it is not true shall have the right to refuse the claim.
We recommend that you read the Claims section of your policy.
Please answer all the questions on this form. If a question does not apply to your claim, please answer 'N/A'.
You must not incr any expense (unless it is to minimise the loss), or admit fault, without our permission.
THE INSURED MUST COMPLETE THE DECLARATION IN PART 'R' OF THIS FORM, AND HAVE IT WITNESSED.

DECLARATION

PLEASE NOTE: Failure to provide full and truthful information could result in the Claim being declined

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.

Sending