Important message for customers wishing to make a claim on their policy

Transcription

1 Important message for customers wishing to make a claim on their policy Before we can action your claim, can you please: Fully complete the attached claim form and statutory declaration Return all these documents to: Co-op Insurance NZ PO Box 9582 Newmarket Auckland or scan and to: claims@coopinsurancenz.co.nz Please note we are unable to advise you on this claim until we have received all of the requested documentation, and all costs (including storage and salvage) will be your responsibility. We will be in touch once we have reviewed your claim. If you have any queries please call us on

2 Policy Number For Office Use Only: Claim Number STOLEN MOTOR VEHICLE INSURANCE CLAIM FORM Please complete all Sections, or draw a line through any question which does not apply Section One - Policy Holder Details Surname: First Name: Middle Name: DOB: Address: Town, City or District: Home Phone No: Work Phone No: Cellphone No: Section Two - Vehicle Details Registration No: Make: Model: Year: Address of where the vehicle was stolen? Where was the vehicle parked? Garage/Carport Parking Area Driveway Roadside Other Section Three - Vehicle Modifications Does your vehicle include any of the following modifiations: (Please tick ) Non standard stereo Non standard mags Turbo (petrol only) Engine Immobilizer Please state full details of any other modifications: Section Four - Details of Theft When was the vehicle Day: Date: Time: am pm stolen? Has the vehicle been recovered? When did you last see the vehicle? Was the vehicle fully locked and secure? Yes No If NO, give details How many sets of keys are there for the vehicle? Where were the keys when the theft occurred? Does the vehicle have an alarm/immobiliser fitted? Yes No If YES, was the alarm set when you left the vehicle? Yes No If you were not the last person in control of the vehicle, please state who was: Surname: First Name: Middle Name: DOB: Address: Town, City or District: Home Phone No: Work Phone No: Cellphone No: Relation to You: (ie wife, son,etc.) Is this person the main driver of the vehicle? Yes No

3 Section Five Details of Damage You must complete this section if the vehicle was recovered Please provide details of damage to the vehicle. Use the diagram to indicate damage, eg damage to left front and bonnet Did the vehicle require towing? Yes No If YES, please provide the name and address of the tow Please provide the location of the vehicle at present company Have quotes been obtained? If so, please attach Panelbeater s Name: Estimated Cost of repair: Section Six - Police Officer Details (if applicable) Were the Police advised of the theft of the vehicle? Yes No If YES, at what time? On what day? On what date? Please attach a copy of the Police Acknowledgement Report Form Officer s name: Officer s QID No: Officer s Station: File Number or Event No: Section Seven - Other Information Have you any idea who may have stolen or vandalised your vehicle? Yes No Have you any idea how entry was gained? Yes No Do you have any other insurance on the vehicle and/or accessories? Yes No Is there finance owing on the vehicle? Yes No Are your vehicle payments up to date? Yes No If NO, please give details Do you have any other insurance on the vehicle and/or modifications? Yes No Have you been trying to sell the vehicle or modifications? Yes No Have you had any motor vehicle accidents or losses in the last 7 years? Yes No Have you had any traffic or criminal convictions in the last 7 years? Yes No Have you any other information relevant to this claim? Please provide details of any witnesses: Section Eight - Witness Details Name: Address: Name: Address: Phone: Phone:

4 Section Nine Declaration I, (insured), declare that the information and answers given above are true in every detail and that all relevant information has been disclosed. I/We authorise the insurer to give to, or obtain from any other party, any information that in the insurer s view, is relevant to this claim. I/We understand that: The claim may be refused if information is untrue or concealed The information is needed before the insurer can decide whether to accept this claim The Privacy Act 1993 entitles me to have access to and, if necessary, request correction of information Signature of Person last in control of the vehicle:: Date: Signature of Policy Holder: Date: When you have completed all the necessary details, scan and the completed claim form to: claims@coopinsurancenz.co.nz or Post to: Co-op Insurance NZ, PO Box 9582, Newmarket AUCKLAND

5 Motor Vehicle Theft Statutory Declaration I, of hereby declare that on a motor vehicle owned/driven by me was stolen and in this regard, I hereby state the following: 1) Vehicle Details Registration number Type Make Year Model Number of owners Engine HP or CC rating Vehicle identification number (VIN) Speedo reading (at time of theft) Warrant of fitness issues by Month of expiry Any hire purchase Name of registered owner * Please attach ownership papers and keys 2) Security Were doors locked? Yes No Were windows fully wound up? Yes No Were keys in ignition or inside vehicle? Yes No Where was the vehicle parked? What time was it left parked? Who discovered the vehicle missing? What date was it discovered missing? What time was it discovered missing? Has theft been reported to the police?

6 3) Condition of Vehicle Colour Condition of paintwork Condition of interior trim Who normally serviced the vehicle? Condition of engine and transmission (attach receipts of engine or mechanical parts reconditioned) Condition of bodywork (list all dents and visible rust) Condition of tyres? Retreads New Percentage of tread left R/F % L/F % R/R % L/R % Spare % Make/type/size R/F L/F R/R L/R Spare What assemblies colour/identifying features? 4) Accessories Please list full details of all extras fitted 5) Have you any suspicions who the offender was?

7 6) Have you any other information relevant to this claim? 7) I, hereby authorise Co-op Insurance NZ to obtain any relevant information under the Official Information Act concerning a which occurred at on or about. The above is an accurate description of the vehicle at the time it was stolen, and I make this solemn declaration conscientiously believing the same to be true and by virtue of the Oaths and Declarations Act Dated this day of Signature Witness (To be witnessed by Justice of the Peace, Solicitor or person authorised to take statutory declarations

8