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

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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 If your vehicle is driveable, call us to seek details of an approved repairer Supply a copy of the Driver s Licence of the person who was driving the vehicle Return all these documents to: Co-op Insurance NZ PO Box 9582 Newmarket Auckland or scan and to: Please note that we are unable to advise you on this claim until we have received all of the required 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 For Office Use Only: Claim Number Policy Number This form SHOULD NOT be used for Stolen or Uninsured Third Party Claims Different claims forms are available for these circumstances MOTOR VEHICLE INSURANCE CLAIM FORM Please complete all Sections Section One - Policy Holder Details Surname: First Middle DOB: Town, City or District: Home Phone No: Work Phone No: Cellphone No: Section Two - Driver Details If the person driving was NOT the policy holder described in Section One, please complete this section Surname: First Middle DOB: Town, City or District: Home Phone No: Work Phone No: Cellphone No: Section Three - Licence Details of the Driver Please complete the following details Expiry Date: Full which you will find on your drivers licence: Restricted Drivers Licence No (5a): Learners Licence Version No (5b): If it is an overseas licence, in which country was it issued? Expiry Date: Are you the main driver of the vehicle? Yes No If NO, state the name of the main driver: Were there any passengers in the car? Yes No If YES, state the names, address and phone numbers:

3 Section Four Previous History This section applies to the driver at the time of the accident Within the last 7 years have you had: Any insurance declined, cancelled or refused to renew? Yes No Any insurance claim denied? Yes No Made any previous insurance claims, regardless of who you were insured with and whether you were to blame? Yes No A charge or fine for an offence in connection with a vehicle? Yes No A charge or fine for an offence in connection with drugs, alcohol, fraud, theft or any other offence? Please explain Yes No Section Five - Vehicle Details Registration No: Make: Model: Year: Section Six - Vehicle Modifications Does your vehicle include any of the following modifications: (Please tick ) Non standard stereo Non standard mags Turbo (petrol only) Engine Immobilizer Please state full details of any other modifications: Section Seven - Details of Accident / Vandalism Date: Day: Time: am pm What speed were you travelling? Kph Location: (state street or intersection name(s) and town accident occurred)

4 Full Description of Accident / Vandalism etc: Sketch of Accident - Please mark your vehicle with X and the other vehicle etc with O Please show: Street Names Road Markings Road Signs Traffic Signals Traffic Islands Distances from kerb Distances between vehicles Direction of travel Which driver do you consider to be at fault? What are your reasons? Section Eight - Police Attendance/Alcohol/Drugs Compulsory In the case of an accident, did a Police Officer attend the scene of the accident? Yes No If YES, please complete Officer details below: In the case of a non-accident, have Police been advised of the incident? Yes No If YES, please attach complaint acknowledgement report form Officer s name: Officer s QID No: Officer s Station: Have you been issued with any Offence Notice by the Police? Yes Had you consumed any drugs during the 8 hours prior No to the accident? Yes No File Number or Event No: If YES, please advise if they were recreational drugs or Had you consumed any alcohol during the 8 hours prior to the drugs for medicinal purposes and state what drugs accident? Yes No they were Were you breath tested? Yes No If YES Pass Fail

5 Section Nine - Witness Details Please provide details of any witnesses (independent and passengers): Independent Witnesses: Passenger Witnesses: Section Ten Details of Damage to Vehicle 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 Estimated Cost of repair:

6 Section Eleven Details of Damage to other Parties involved - Vehicle or Property Was another vehicle or property damaged in the accident? Yes No If YES, please provide the following information. (If more than one vehicle involved, please supply details on a separate piece of paper) Name and address of owner and/or driver of other damaged vehicle or property: Phone No: Make and Registration Number of other vehicle: Name and address of Insurance Company of the other vehicle or property: Phone No: Brief details of the damage to the other vehicle or property: Section Twelve Driving Conditions For each of the following categories, circle the number(s) that best describes the conditions at the time of the accident Type of Accident 1 Other party hit us 2 We hit another vehicle 3 Hit cyclist 4 Hit pedestrian 5 Hit stationary object 6 Hit animal 7 Vandalism 8 Theft 9 Windscreen 10 Driver lost control Weather Conditions 1 Fine 2 Overcast 3 Raining 4 Strong wind 5 Poor visibility 6 Glare 7 Snow or ice Road Conditions 1 Dry 2 Wet 3 Flood 4 Slippery 5 Icy 6 Muddy 7 Unsealed Road Type 1 Open road 2 70 km/h zone 3 50 km/h zone 4 Intersection 5 Private property 6 Company premises 7 Car park 8 Farm 9 Forestry 10 Motorway Vehicle Was 1 Stationary 2 Moving off 3 Slowing down 4 Overtaking 5 Changing lanes 6 On a roundabout /intersection 7 Making a U turn 8 Reversing 9 Unattended 10 Proceeding normally Damage to Vehicle 1 Front 2 Rear 3 Driver s side 4 Passenger s side 5 Bonnet 6 Roof 7 Multiple 8 None \

7 Section Thirteen Additional Information Please provide any other information you feel relevant Section Fourteen Declaration The driver of the vehicle must fill his/her name in the declaration below: I, (driver), 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 Driver: Date: Signature of Policy Holder: Date: When you have completed all the necessary details: Scan and the claim form to: Or Post to: Co-op Insurance NZ, PO Box 9582, Newmarket AUCKLAND

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