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 and statutory declaration Return all these documents to: Co-op Insurance NZ PO Box 9582 Newmarket Auckland or scan and to: 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 UNINSURED THIRD PARTY INSURANCE CLAIM FORM Please complete all Sections, or draw a line through any question which does not apply Section One - Our Policy Holder Details Surname: First Name: Middle Name: DOB: Town, City or District: Home Phone No: Work Phone No: Cellphone No: Section Two Our Driver s Details Surname: First Name: Middle Name: DOB: Town, City or District: Home Phone No: Work Phone No: Cellphone No: Section Three Our Vehicle Details Registration No: Make: Model: Year: Section Four Third Party s Details Surname: First Name: Middle Name: DOB: Town, City or District: Home Phone No: Work Phone No: Cellphone No: Were there any passengers in the car? Yes No If YES, state the names, address and phone numbers: Name: Name: Phone: Phone: Section Five Third Party s Vehicle Details Registration No: Make: Model: Year: CC Rating: Is your vehicle financed? Yes No Finance Company: Contract No: Do you have any insurance policy on your vehicle? Yes No If YES, please state Name of Company: Address of Company: Your Policy Number:

3 Section Six - Details of Accident Date: Day: Time: am pm Location: (state street or intersection name(s) and town accident occurred) What speed were you travelling? Kph Full Description of Accident: 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 Seven - Police Officer Details (if applicable) Did a Police Officer attend the scene of the accident? Yes No If YES, please complete Officer details below: Officer s name: Officer s QID No: Officer s Station: File Number or Event No:

4 Section Eight Details of Damage to Vehicle Please provide details of damage to your 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 Nine 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

5 Section Ten Additional Information Please provide any other information you feel relevant Section Eleven Declaration 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 understand that provision of this form and completion of the form does not constitute any admission of liability by Credit Union Insurance either under their policy holder s insurance policy or otherwise. 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

6 Section Twelve Statutory Declaration TO BE COMPLETED BY THE REGISTERED OWNER OF THE UNINSURED VEHICLE. REGISTRATION PLATE: I, OF Solemnly and sincerely declare that at the time of the accident my motor vehicle was not insured in any way whatsoever. This vehicle is subject to security / finance by Is not subject to any security / finance. I make this solemn declaration conscientiously believing the same to be true and by virtue of the Oaths and Declarations Act Signed: (registered owner of the uninsured vehicle) Declared at: this day of 20. Signed: Justice of the Peace (or any person authorised to take a Statutory Declaration) Note: Section III of the Crimes Act 1961 makes liable to imprisonment for a term not exceeding three years every person who, on any occasion on which he is required or permitted by law to make any declaration before any person authorised by law to receive it, makes a declaration that would amount to perjury if made on Oath in a judicial proceeding.

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

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