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

Size: px
Start display at page:

Download "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: 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: 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

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

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

More information

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

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

More information

STOLEN VEHICLE DECLARATION

STOLEN VEHICLE DECLARATION STOLEN VEHICLE DECLARATION To enable us to promptly consider your claim, please complete and return this form. NB: Please answer all questions. Write N/A or Nil if necessary. Use extra pages if necessary.

More information

Motor Vehicle. Claim Report

Motor Vehicle. Claim Report Motor Vehicle Claim Report Please retain this page for your information IMPORTANT INFORMATION ABOUT YOUR CLAIM This form must be completed and signed by the person who was driving your vehicle, or the

More information

How To Fill Out A Claim Form For A Car Accident In The Uk

How To Fill Out A Claim Form For A Car Accident In The Uk Motor Vehicle Claim Report Please retain this page for your information IMPORTANT INFORMATION ABOUT YOUR CLAIM This form must be completed and signed by the person who was driving your vehicle, or the

More information

Motor Vehicle Claim Form

Motor Vehicle Claim Form phone: +64 9 377 4314 fax: +64 9 373 4882 email: claims@icib.co.nz web: www.icib.co.nz Level 7, 26 Hobson Street Auckland, PO Box 3174 Auckland 1140, New Zealand Motor Vehicle Claim Form Policy Details

More information

PLEASURE CRAFT / HULL CLAIM FORM

PLEASURE CRAFT / HULL CLAIM FORM PLEASURE CRAFT / HULL CLAIM FORM INSURANCE BROKERS The Issue of this Form is not an Admission of Liability by Insurer Policy # : Claim # : Please complete and return this claim form as soon as possible,

More information

motor vehicle insurance for privately owned non-commercial vehicles motor vehicle theft claim report Insurer CGU Insurance Limited ABN 27 004 478 371

motor vehicle insurance for privately owned non-commercial vehicles motor vehicle theft claim report Insurer CGU Insurance Limited ABN 27 004 478 371 motor vehicle insurance for privately owned non-commercial vehicles motor vehicle theft claim report Insurer CGU Insurance Limited ABN 27 004 478 371 CGU Insurance Limited ABN 27 004 478 371 Please retain

More information

Motor Accident Claim Form Insured Section

Motor Accident Claim Form Insured Section Motor Accident Claim Form Insured Section Date Insured Name Insured Licence Code Licence : Date of Issue Insured Id Policy Insured Address Suburb Town Province Code Contact Person Landline Number Fax Number

More information

Home Insurance. Claim Report

Home Insurance. Claim Report Home Insurance Claim Report CGU Insurance Limited ABN 27 004 478 371 AFSL 238291 Please retain this page for your information About your claim Most policies allow for replacement of property with the nearest

More information

MOTOR VEHICLE CLAIM FORM (Accident or Theft)

MOTOR VEHICLE CLAIM FORM (Accident or Theft) Cowden Group MOTOR VEHICLE CLAIM FORM (Accident or Theft) The supply or acceptance of this form is not an admission of liability on the part of your Insurer 1. Your Details Policy No Expiry of Insured

More information

MOTOR VEHICLE CLAIM FORM

MOTOR VEHICLE CLAIM FORM MOTOR VEHICLE CLAIM FORM The Issue of this Form is not an Admission of Liability by Insurers We understand the difficulties arising from your accident. Please complete and return this claim form as soon

More information

MOTOR VEHICLE CLAIM FORM

MOTOR VEHICLE CLAIM FORM MOTOR VEHICLE CLAIM FORM (If there is not enough room on this form for your answers, please attach a separate sheet, indicating the Section and Question you wish to complete.) Please lodge your claim to

More information

Motor Vehicle Insurance Claim

Motor Vehicle Insurance Claim Motor Vehicle Insurance Claim The supply or acceptance of this form is not an admission of liability on the part of the insurer. Please complete ALL sections of this claim form. Unless specifically arranged

More information

MOTOR TRADE CLAIM FORM

MOTOR TRADE CLAIM FORM Insurance Company Limited MOTOR TRADE CLAIM FORM First Response Claims Line 0845 373 1300 Fax 020 7068 7740 Email claims@tradex.com www.tradex.com Policyholder s Name Company Name Policy No. (cover note

More information

1. Your Details 2. Insured Vehicle Description

1. Your Details 2. Insured Vehicle Description MOTOR VEHICLE CLAIM The issue or acceptance of this form is not to be construed as an admission of liability on the part of the company. Shaded areas for office use only. Please print clearly. Claim Number

More information

Motor Vehicle Insurance Claim. Insured

Motor Vehicle Insurance Claim. Insured INSURANCE BROKERS 22 Welsford Street, Shepparton PO Box 1377, Shepparton VIC 3632 www.ggib.com.au Phone (03) 5821-7777 Fax (03) 5822-2916 Email ggib@ggib.com.au ABN 52 858 454 162 AFS 237 533 Motor Vehicle

More information

Motor Vehicle Claim Form

Motor Vehicle Claim Form SSAA Insurance Brokers Pty Ltd Phone (08) 8332 0281 The Precinct Freecall 1800 808 608 Suite 14, 539 Greenhill Road Facsimile (08) 8332 0303 539 Greenhill Road Email insurance@ssaains.com.au Hazelwood

More information

Motor Vehicle Claim Form

Motor Vehicle Claim Form 1st Floor, 50 Hindmarsh Square Adelaide SA 5000 PO Box 6095 Halifax St Adelaide 5000 Phone 08 8413 6300 Facsimile 08 82119838 enquiries@brecknock.com.au brecknock.com.au Motor Vehicle Claim Form We re

More information

Telephone numbers Home Work Mobile. Are you the registered owner? Yes No. Was an immobiliser fitted to the vehicle? Yes No

Telephone numbers Home Work Mobile. Are you the registered owner? Yes No. Was an immobiliser fitted to the vehicle? Yes No Motor Theft Claim Form Please help us to help you by: making sure the information you give is as clear and complete as possible completing all the relevant sections of this form remembering to sign and

More information

Give details of your vehicle involved in the accident - Year Make (e.g. Holden) Model (e.g. Commodore) Registration No.

Give details of your vehicle involved in the accident - Year Make (e.g. Holden) Model (e.g. Commodore) Registration No. Echelon Claims Services is a division of Echelon Australia Pty Ltd ABN 96 085 720 056 Address: PO Box 7170, Hutt Street, Adelaide South Australia 5000 Ph (08) 8235 6455 Free call 1800 640 009 Facsimile

More information

Motor Vehicle Insurance Claim. Insured

Motor Vehicle Insurance Claim. Insured Suite 5 & 6 156 Oxford St, Leederville WA 6007 PO Box 495, Leederville WA 6903 Freecall: 1800 776 747 Facsimile: 1800 194 525 Email: info@mynfib.com.au ABN 23 108 296 064 National Franchise Insurance Brokers

More information

HEAVY MOTOR FLEET INSURANCE CLAIM FORM

HEAVY MOTOR FLEET INSURANCE CLAIM FORM HEAVY MOTOR FLEET INSURANCE CLAIM FORM Take precautions to ensure that no further damage or loss occurs to the vehicle. Where possible have the vehicle moved to a secure location if not drivable. Obtain

More information

motor vehicle insurance application for privately owned non-commercial vehicles (excluding motorcycles) motor vehicle

motor vehicle insurance application for privately owned non-commercial vehicles (excluding motorcycles) motor vehicle motor vehicle insurance application for privately owned non-commercial vehicles (excluding motorcycles) motor vehicle CGU Insurance Limited ABN 27 004 478 371. An IAG Company. Please read the following

More information

MOTOR VEHICLE CLAIM FORM

MOTOR VEHICLE CLAIM FORM MOTOR VEHICLE CLAIM FORM Dear Policyholder, We re sorry to hear you ve had an accident. Our aim is to settle your claim as quickly as possible. You can help us do this by ensuring the enclosed claim form

More information

Motor vehicle insurance claim form

Motor vehicle insurance claim form Motor vehicle insurance claim form Suva: 231 Waimanu Rd Phone: 331 1055 Fax: 330 3475 Nadi: Main Street Phone: 670 1451 Fax: 6701221 Important Notes To assist Dominion Insurance Limited ( us/our/we ) process

More information

Motor Vehicle Claim Form

Motor Vehicle Claim Form Motor Vehicle Claim Form Dear Policyholder, We re sorry to hear you ve had an accident. Our aim is to settle your claim as quickly as possible. You can help us do this by ensuring the enclosed claim form

More information

home insurance home claim report

home insurance home claim report home insurance home claim report CGU Insurance Limited ABN 27 004 478 371. An IAG Company. Please retain this page for your information About your claim Most policies allow for replacement of property

More information

Steadfast Taswide Pty Ltd ABN 24 092 613 664 AFS Licence No. 238451. enquiries@steadfasttaswide.com.au www.steadffasttaswide.com.

Steadfast Taswide Pty Ltd ABN 24 092 613 664 AFS Licence No. 238451. enquiries@steadfasttaswide.com.au www.steadffasttaswide.com. WHK Centre, Level 4 142 Elizabeth Street, Hobart TAS 7000 Ph (03) 6231 3360 Fax (03) 6231 6053 Steadfast Taswide Pty Ltd ABN 24 092 613 664 AFS Licence. 238451 enquiries@steadfasttaswide.com.au www.steadffasttaswide.com.au

More information

Motor Vehicle Accident Claim Form

Motor Vehicle Accident Claim Form Motor Vehicle Accident Claim Form THE COMPLETION OF THIS FORM AND ITS RECEIPT BY US IS NOT AN INDICATION THAT WE ACCEPT ANY LIABILITY. WE HAVE QUALITY REPAIRERS TO HELP YOU IN THE EVENT OF A CLAIM. PLEASE

More information

MOTOR ACCIDENT FORM. General Information. Insured. Daytime phone no. Date of Birth Occupation

MOTOR ACCIDENT FORM. General Information. Insured. Daytime phone no. Date of Birth Occupation MOTOR ACCIDENT FORM Please complete this form and return to Sagar Insurances, 30 Willow St, Accrington, BB5 1LU T 01254 391411 : F 01254 872720 : E claims@sagarinsurances.co.uk Please note, if anyone has

More information

Application for a licence to operate private hire vehicles

Application for a licence to operate private hire vehicles Application for a licence to operate private hire vehicles Please read the notes at the back of this form carefully before completing the application Type of Application (place a tick in the appropriate

More information

MOTORCYCLE CLAIM FORM ACCIDENT DAMAGE (The issue of this form is not an admission of liability)

MOTORCYCLE CLAIM FORM ACCIDENT DAMAGE (The issue of this form is not an admission of liability) MOTORCYCLE CLAIM FORM ACCIDENT DAMAGE (The issue of this form is not an admission of liability) This form should be completed and forwarded to - ECHELON CLAIMS SERVICES GPO Box 1693 Adelaide SA 5001 Facsimile:

More information

MOTOR VEHICLE ACCIDENT Claim Report

MOTOR VEHICLE ACCIDENT Claim Report MOTOR VEHICLE ACCIDENT Claim Report HBA General Insurance and Mutual Community General Insurance Insurer: Mutual Community General Insurance Pty Ltd Abn 59 007 895 543 Please retain this page for your

More information

2. The Insured (Vehicle owner)

2. The Insured (Vehicle owner) mobile plant liability claim form WFI Insurance Limited, ABN 24 000 036 279 The issue of this form must not be taken as an admission of liability. Form is to be completed as far as possible by the driver

More information

motor vehicle motor vehicle insurance for privately owned non-commercial vehicles accident claim report

motor vehicle motor vehicle insurance for privately owned non-commercial vehicles accident claim report motor vehicle insurance for privately owned non-commercial vehicles motor vehicle accident claim report Insurer CGU Insurance Limited ABN 27 004 478 371 An IAG Company CGU Insurance Limited ABN 27 004

More information

MOTOR VEHICLE CLAIM FORM

MOTOR VEHICLE CLAIM FORM MOTOR VEHICLE CLAIM FORM How to obtain a quick response to your claim: 1. Make sure that you fully answer all questions 2. Attach a copy of the Driver s Licence for the driver of the vehicle at the time

More information

MOTORCYCLE INSURANCE CLAIM FORM

MOTORCYCLE INSURANCE CLAIM FORM MOTORCYCLE INSURANCE CLAIM FORM PO BOX 6156, NORTH SYDNEY, NSW, 2059 PHONE: 1300 781 448 FAX: 02 8920 1275 E-MAIL: CLAIMS@MI-BIKE.COM.AU Please ensure that all questions are answered in full in as much

More information

MOTOR VEHICLE ACCIDENT CLAIM REPORT

MOTOR VEHICLE ACCIDENT CLAIM REPORT MOTOR VEHICLE ACCIDENT CLAIM REPORT CGU Insurance Limited ABN 27 004 478 371 Please retain this page for your information ABOUT YOUR CLAIM Please obtain one quotation for the repair of your vehicle from

More information

Commercial Motor and Motor Fleet Claim Form

Commercial Motor and Motor Fleet Claim Form Commercial Motor and Motor Fleet Claim Form The completion of this form and its receipt by us is not an indication that we accept any liability. Please print in block letters and answer all Questions where

More information

Motor Vehicle Accident Report Form

Motor Vehicle Accident Report Form Motor Vehicle Accident Report Form 1300 725 788 Your Car, Your Choice Know Your Rights Service & Quality Guaranteed One Call Does It All Owner s Particulars (PLEASE COMPLETE IN BLOCK LETTERS) Full Name

More information

CLAIM FOR TRANSPORT SUBSIDY FOR ANIMAL WELFARE

CLAIM FOR TRANSPORT SUBSIDY FOR ANIMAL WELFARE CLAIM FOR TRANSPORT SUBSIDY FOR ANIMAL WELFARE NOTE: Submit all claim forms with original invoices, receipts and other documents attached. All invoices will be copied and returned to the claimant. Initial

More information

Community Underwriting Motor Claim Form

Community Underwriting Motor Claim Form Community Underwriting Motor Claim Form About the Insurer Calliden Insurance Limited (Calliden) (ABN 47 004 125 268), is a public company incorporated in Australia. It is authorised under the Australian

More information

COMMERCIAL MOTOR CLAIM FORM

COMMERCIAL MOTOR CLAIM FORM COMMERCIAL MOTOR CLAIM FORM Please complete in full all sections of this claims form and return it to Insuret as soon as possible after the accident. Unless specifically arranged beforehand, no repairs

More information

MOTOR ACCIDENT CLAIM FORM

MOTOR ACCIDENT CLAIM FORM MOTOR ACCIDENT CLAIM FORM INSURED Insurer Policy No. Occupation VEHICLE Make Model Odometer Reading Value Tare Gross Vehicle Mass Registration No Date of purchase Purchase price If vehicle is subject to

More information

MOTOR ACCIDENT CLAIM FORM

MOTOR ACCIDENT CLAIM FORM MOTOR ACCIDENT CLAIM FORM Please do not obtain any quotations. We will appoint an Assessor to assess the damage to your vehicle. Clear copy of Driver s licence to be submitted with claim form. Insured

More information

Boat Insurance Claim Form

Boat Insurance Claim Form Boat Insurance Claim Form 5. Incident Details The issue or acceptance of this form is not to be construed as an admission of liability on the part of the Company. Please provide complete details to the

More information

CARMINDER Vehicle Protection Insurance. Covering you co-operatively

CARMINDER Vehicle Protection Insurance. Covering you co-operatively CARMINDER Vehicle Protection Insurance Covering you co-operatively Affordable vehicle insurance to protect you and your car: Comprehensive cover (includes windscreen, keys & locks cover at no extra cost

More information

Motor Incident Claim Form

Motor Incident Claim Form Motor Incident Claim Form Policy number Claim number This form should be filled in by the person named as the policyholder on the policy schedule. For accident reporting, please complete all sections on

More information

Claim form Motor Vehicle

Claim form Motor Vehicle Claim form Motor Vehicle The Company does not admit Liability by the issue of this Form. It is issued to enable the Insured to lodge their written statement of claim. CLAIM NUMBER OFFICE USE ONLY Claim

More information

secure boat claim form

secure boat claim form secure boat claim form NOTES: The issue of this Claim Form is not an admission of liability on our part. All questions must be fully answered in either black or blue pen. Please print clearly and tick

More information

THE COMPANY DOES NOT ADMIT LIABILITY BY THE ISSUE OF THIS FORM. IT IS ISSUED TO ENABLE THE INSURED TO LODGE THEIR WRITTEN STATEMENT OF CLAIM.

THE COMPANY DOES NOT ADMIT LIABILITY BY THE ISSUE OF THIS FORM. IT IS ISSUED TO ENABLE THE INSURED TO LODGE THEIR WRITTEN STATEMENT OF CLAIM. CLAIM FORM Motor Vehicle The Company does not admit Liability by the issue of this Form. It is issued to enable the Insured to lodge their written statement of claim. CLAIM NUMBER OFFICE USE ONLY CLAIM

More information

MOTOR ACCIDENT REPORT (NOT FOR USE ON THEFT CLAIMS OR MOTOR TRADE)

MOTOR ACCIDENT REPORT (NOT FOR USE ON THEFT CLAIMS OR MOTOR TRADE) Insurance Company Limited MOTOR ACCIDENT REPORT (NOT FOR USE ON THEFT CLAIMS OR MOTOR TRADE) First Response Claims Line 0845 373 1300 Fax 020 7068 7740 Email claims@tradex.com www.tradex.com Policyholder

More information

Motor Vehicle Claim Form

Motor Vehicle Claim Form Motor Vehicle Claim Form MOTOR VEHICLE CLAIM FORM Dear Policyholder, We re sorry to hear you ve had an accident. Our aim is to settle your claim as quickly as possible. You can help us do this by ensuring

More information

8 THE KATE EDGER EDUCATIONAL CHARITABLE TRUST MASTER S DEGREE AWARDS PURPOSE

8 THE KATE EDGER EDUCATIONAL CHARITABLE TRUST MASTER S DEGREE AWARDS PURPOSE Appendix 8 THE KATE EDGER EDUCATIONAL CHARITABLE TRUST MASTER S DEGREE AWARDS PURPOSE To assist women graduates to carry out study for a Master s Degree at an approved institution in the Auckland area.

More information

MOTOR VEHICLE CLAIM FORM

MOTOR VEHICLE CLAIM FORM MOTOR VEHICLE CLAIM FORM Dear Policyholder, We re sorry to hear you ve had an accident. Our aim is to settle your claim as quickly as possible. You can help us do this by ensuring the enclosed claim form

More information

Motor Vehicle. Claim Form PLEASE RETURN COMPLETED FORM TO YOUR JLT OFFICE:

Motor Vehicle. Claim Form PLEASE RETURN COMPLETED FORM TO YOUR JLT OFFICE: Motor Vehicle Claim Form PLEASE RETURN COMPLETED FORM TO YOUR JLT OFFICE: GPO Box 1693 ADELAIDE SA 5001 Tel +61 (0)8 8235 6446 Fax +61 (0)8 8235 6448 PO Box 925 ALBURY NSW 2640 Tel +61 (0)2 6057 3333 Fax

More information

Motor Vehicle Accident Claim Form

Motor Vehicle Accident Claim Form Motor Vehicle Accident Claim Form Please note, no repairs are to commence without the consent of your insurer. -+ A trading name of Austbrokers RIS Pty Ltd ABN 25 094 825 859 AFS Licence No. 239 291 Level

More information

MOTORCYCLE INSURANCE QUESTIONNAIRE

MOTORCYCLE INSURANCE QUESTIONNAIRE MOTORCYCLE INSURANCE QUESTIONNAIRE Contact Details Contact Person Postal Address Phone Number Company Name (if applicable) Postcode Email Address Cover Type Comprehensive Agreed Value Third Party, Fire

More information

Motor Vehicle. Accident Claim Form COMPLAINTS PROCEDURE. Financial Ombudsman Service. Privacy Statement. General Insurance Code of Practice

Motor Vehicle. Accident Claim Form COMPLAINTS PROCEDURE. Financial Ombudsman Service. Privacy Statement. General Insurance Code of Practice COMPLAINTS PROCEDURE Enthusiast Underwriting Pty Ltd is a member of the Financial Ombudsman Service. This independent service is provided to the insuring public at no cost and aims to resolve claims complaints

More information

Corporate Services Department Application Form for Senior Citizens Flat Version: July 2014

Corporate Services Department Application Form for Senior Citizens Flat Version: July 2014 Corporate Services Department Application Form for Senior Citizens Flat Version: July 2014 1. Full name (s) Title Surname First Names Date of Birth a) b) Current Address: Contact Phone No: 2. Existing

More information

Motor Accident Report Form

Motor Accident Report Form Motor Accident Report Form THIS FORM MUST BE COMPLETED BY THE POLICYHOLDER AND/OR THE AUTHORISED DRIVER PLEASE HELP US TO HELP YOU BY: MAKING SURE THE INFORMATION YOU GIVE IS AS TRUTHFUL AND ACCURATE AS

More information

Landlords Residential Property Insurance Claim Report

Landlords Residential Property Insurance Claim Report Landlords Residential Property Insurance Claim Report CGU Insurance Limited ABN 27 004 478 371 Please retain this page for your information About your claim We will contact you as quickly as possible about

More information

Motor Accident Claim Form

Motor Accident Claim Form Motor Accident Claim Form Agricultural Commercial & Private Vehicles www.towergateunderwriting.co.uk Guidance Notes Most delays in settling claims arise because claim forms are not fully completed or requested

More information

Claim Form Commercial Hull & Boat Insurance

Claim Form Commercial Hull & Boat Insurance QBE INSURANCE (AUSTRALIA) LIMITED ABN 78 003 191 035 Claim Form Commercial Hull & Boat Insurance All questions on this claim form must be answered The Insured Insured s name Surname Given (s) Are you registered

More information

VEHICLE ACCIDENT CLAIM FORM

VEHICLE ACCIDENT CLAIM FORM Please help us to help you by: completing all relevant questions in full as this can avoid the need for further enquiry and possible delay in settling your claim signing and dating page 7 of this form

More information

Tradewise Insurance Company Ltd

Tradewise Insurance Company Ltd Tradewise Insurance Company Ltd MOTOR ACCIDENT REPORT FORM Ensure all sections of this form are completed fully. Also note that any attempt to defraud Underwriters will result in criminal prosecution.

More information

Application Form for the Special Support Service for Former Sawmill Workers Exposed to Pentachlorophenol (PCP)

Application Form for the Special Support Service for Former Sawmill Workers Exposed to Pentachlorophenol (PCP) Application Form for the Special Support Service for Former Sawmill Workers Exposed to Pentachlorophenol (PCP) Please read the factsheet General Information for Patients before completing this form Use

More information

MOTOR VEHICLE INSURANCE PROPOSAL FORM

MOTOR VEHICLE INSURANCE PROPOSAL FORM MOTOR VEHICLE INSURANCE PROPOSAL FORM In completing the Proposal Form please ensure that questions are answered fully and accurately and where necessary schedules giving further explanation are provided.

More information

home contents transit

home contents transit home contents transit insurance Insurer CGU Marine Insurance A Division of CGU Insurance Limited ABN 27 004 478 371 An IAG Company claim report home contents transit CGU Marine Insurance A Division of

More information

CLAIM FORM A. To be completed by the registered operator/ owner or driver of the vehicle

CLAIM FORM A. To be completed by the registered operator/ owner or driver of the vehicle Notice of Accident CLAIM FORM A To be completed by the registered operator/ owner or driver of the vehicle If you have suffered Personal Injury resulting directly from this motor accident and wish to claim

More information

Motor Accident Claim Form

Motor Accident Claim Form Motor Accident Claim Form Agricultural Commercial & Private Vehicles www.towergateunderwriting.co.uk Guidance Notes Most delays in settling claims arise because claim forms are not fully completed or requested

More information

Are you registered for GST? Yes No. To what extent are you entitled to claim an Input Tax Credit on the GST applicable to the premium?

Are you registered for GST? Yes No. To what extent are you entitled to claim an Input Tax Credit on the GST applicable to the premium? Public Liability Claim Form Note: The issue of this claim form is not admission of liability on our part. All questions must be fully answered. Please print clearly and tick the appropriate boxes to indicate

More information

MOTOR VEHICLE ACCIDENT CLAIM FORM

MOTOR VEHICLE ACCIDENT CLAIM FORM MOTOR VEHICLE ACCIDENT CLAIM FORM Insurer: Policy No.: VAT Reg. No.: Insured Identity No.: Occupation: Phone No.: Vehicle Reg No.: Make: Tare: Gross Vehicle Mass: Kilometers: Date Purchased: Price Paid:

More information

Surname Full given name Date of birth. Private phone no. Business phone no. Mobile phone no. Fax no. ( ) ( ) ( )

Surname Full given name Date of birth. Private phone no. Business phone no. Mobile phone no. Fax no. ( ) ( ) ( ) Golf Sporting Equipment Claim Form THE COMPANY DOES NOT ADMIT LIABILITY BY THE ISSUE OF THIS FORM. IT IS ISSUED TO ENABLE THE INSURED TO LODGE A WRITTEN STATEMENT OF CLAIM. CASE/CLAIM NUMBER Important

More information

Application for a Licence to drive a Hackney Carriage/Private Hire Vehicle in the Borough of High Peak

Application for a Licence to drive a Hackney Carriage/Private Hire Vehicle in the Borough of High Peak a 0845 129 77 77 High Peak Borough Council www.highpeak.gov.uk Application for a Licence to drive a Hackney Carriage/Private Hire Vehicle in the Borough of High Peak Information contained in this form

More information

Holburn Holdings (Pty) Limited Insurance Brokers VAT No. 4690259439

Holburn Holdings (Pty) Limited Insurance Brokers VAT No. 4690259439 Holburn Holdings (Pty) Limited Insurance Brokers VAT No. 4690259439 Block C, Abrey Eco Park, 5 Abrey Road, Kloof, 3610 FSP Licence No. 45159 P.O. Box 198, Gillitts, 3603 031 7640481 Fax: 031 7640178 or

More information

Motor Accident Notification Form (MANF)

Motor Accident Notification Form (MANF) Motor Accident tification Form (MANF) As prescribed under section 84(2)(a) of the Road Transport (Third-Party Insurance) Act 2008 For Compulsory Third-Party (CTP) Insurance Claims in the Australian Capital

More information

KiwiSaver First-Home Deposit Subsidy PRE-APPROVAL /APPROVAL APPLICATION FORM

KiwiSaver First-Home Deposit Subsidy PRE-APPROVAL /APPROVAL APPLICATION FORM KiwiSaver First-Home Deposit Subsidy PRE-APPROVAL /APPROVAL APPLICATION FORM and KiwiSaver First-Home Withdrawal DETERMINATION FOR PREVIOUS HOME OWNER FORM KiwiSaver First-Home Deposit Subsidy PRE-APPROVAL/APPROVAL

More information

MOTOR ACCIDENT CLAIM FORM

MOTOR ACCIDENT CLAIM FORM MOTOR ACCIDENT CLAIM FORM Broker details Broker name Claim number: Jhb Policy number: Jhb Certificate number Insured details Full name and surname Occupation ID VAT number Postal and code Work tel Home

More information

COMMERCIAL VEHICLE PROPOSAL FORM YOU LL ONLY NEED TO WORRY ABOUT THE TRAFFIC

COMMERCIAL VEHICLE PROPOSAL FORM YOU LL ONLY NEED TO WORRY ABOUT THE TRAFFIC COMMERCIAL VEHICLE PROPOSAL FORM YOU LL ONLY NEED TO WORRY ABOUT THE TRAFFIC Introduction Choice of Cover Third Party Fire and Theft You are covered for liability to third parties (including passengers)

More information

Quotation Request and Proposal

Quotation Request and Proposal Quotation Request and Proposal Richard Bowen 0800 287 287 Managing Broker MultiSure Ltd 86 Normandale Road, Lower Hutt 5010 Ph: (04) 589 3319 Fax: (04) 587 0258 Email: richard@multisure.co.nz Philip Toohill

More information

Application for Withdrawal Significant Financial Hardship

Application for Withdrawal Significant Financial Hardship KiwiSaver Act 2006 Application for Withdrawal Significant Financial Hardship Use this form to apply for a withdrawal from your KiwiSaver account if you are experiencing, or likely to experience, Significant

More information

Motor Accident Report Form

Motor Accident Report Form Motor Accident Report Form Tel: 01423 876000 Rural Insurance Group Limited The Lenz Hornbeam Park Harrogate HG2 8RE Fax: 01423 874127 INSURED Motor Accident Report Form Policy. Name Home Tel.. Work Tel..

More information

Personal Accident or Sickness Claim

Personal Accident or Sickness Claim INSURANCE BROKERS 22 Welsford Street, Shepparton PO Box 1377, Shepparton VIC 3632 www.ggib.com.au Phone (03) 5821-7777 Fax (03) 5822-2916 Email ggib@ggib.com.au ABN 52 858 454 162 AFS 237 533 Personal

More information

PUBLIC/PERSONAL LIABILITY CLAIM FORM

PUBLIC/PERSONAL LIABILITY CLAIM FORM ACE Insurance Limited PUBLIC/PERSONAL LIABILITY CLAIM FORM McKenna Hampton Pty Ltd "Kandahar House" Level 1, 41-43 Ord Street West Perth WA 6005 PO Box 204, West Perth WA 6872 Phone: 08 6142 0000 Fax:

More information

APPLICATION FOR COMPENSATION 1 (Where there is no Court Order) Criminal Offence Victims Act S.33 Criminal Code S.663D

APPLICATION FOR COMPENSATION 1 (Where there is no Court Order) Criminal Offence Victims Act S.33 Criminal Code S.663D RETURN FORMS TO: Your Legal Representatives Or Criminal Injury Compensation Unit Department of Justice & Attorney-General GPO Box 149 BRISBANE QLD 4001 APPLICATION FOR COMPENSATION 1 (Where there is no

More information

Registration as a Physiotherapist within the Special Purpose Scope of Practice: Postgraduate Physiotherapy Student

Registration as a Physiotherapist within the Special Purpose Scope of Practice: Postgraduate Physiotherapy Student APPLICATION FORM Registration as a Physiotherapist within the Special Purpose Scope of Practice: Postgraduate Physiotherapy Student Please complete this Application Form with reference to the Application

More information

CLAIM FORM FREQUENTLY ASKED QUESTIONS. Q: How long will it take for me to receive a response to my claim?

CLAIM FORM FREQUENTLY ASKED QUESTIONS. Q: How long will it take for me to receive a response to my claim? CLAIM FORM FREQUENTLY ASKED QUESTIONS Q: How long will it take for me to receive a response to my claim? A: We are committed to providing a quality service - you should expect to receive a response from

More information

NATIONAL INSURANCE TRUST FUND No: 70, D.R. Wijewardana Mawatha, Colombo-10 Tel- 0114873901-905, Fax -0112431145. Motor Accident Claim forms

NATIONAL INSURANCE TRUST FUND No: 70, D.R. Wijewardana Mawatha, Colombo-10 Tel- 0114873901-905, Fax -0112431145. Motor Accident Claim forms NATIONAL INSURANCE TRUST FUND No: 70, D.R. Wijewardana Mawatha, Colombo-10 Tel- 0114873901-905, Fax -0112431145 Motor Accident Claim forms Please complete this form in Block Capitals. Answer all questions

More information

HERTZ Personal Accident & Effects Claim Form

HERTZ Personal Accident & Effects Claim Form HERTZ Personal Accident & Effects Claim Form Trust Name: ABN: (The issue of this form is not an admission of liability) JLT (Hertz PA/PE Cover) Discretionary Trust Arrangement This form should be completed

More information

Motor accident. Claim form. telephone 01 667 0666 fax 01 667 0644 website www.zurich.ie 06/08 FI 44766

Motor accident. Claim form. telephone 01 667 0666 fax 01 667 0644 website www.zurich.ie 06/08 FI 44766 Zurich House Ballsbridge park Dublin 4 telephone 01 667 0666 fax 01 667 0644 website www.zurich.ie ZURICH INSURANCE IRELAND LIMITED IS REGULATED BY THE FINANCIAL REGULATOR Claim form Motor accident 30

More information

GIO Claim Notification Guide Motor

GIO Claim Notification Guide Motor GIO Claim Notification Guide Motor Date of Procedure: June 2015 Version: 1.0 ON BEHALF OF THE Table of Contents GIO Claims Notifications Motor... 3 Treasury Managed Fund (TMF)... 4 What is a claim?...

More information

Property Claim Report

Property Claim Report Property Claim Report This form is to be used for reporting a claim for lost, stolen or damaged property, including: Accidental damage Illegal use of credit card Accidental loss Impact Burglary Lightning

More information

General Insurance Claim

General Insurance Claim WHK Centre, Level 4 142 Elizabeth Street, Hobart TAS 7000 Ph (03) 6231 3360 Fax (03) 6231 6053 Steadfast Taswide Pty Ltd ABN 24 092 613 664 AFS Licence. 238451 enquiries@steadfasttaswide.com.au www.steadffasttaswide.com.au

More information

APPLICATION FOR. License Fee Only. Non- NZTA

APPLICATION FOR. License Fee Only. Non- NZTA C4:08-15 NEW ZEALAND THOROUGHBRED RACING INC PO Box 38386, WMC Telephone: (04) 576 6240 Facsimile: (04) 568 8866 Web: www.nzracing.co.nz Email: licensing@nzracing.co.nz APPLICATION FOR Non- NZTA License

More information

+ Choice of Repairer. 4WD Vehicle Insurance Comparison. Affinity 4WD Insurance

+ Choice of Repairer. 4WD Vehicle Insurance Comparison. Affinity 4WD Insurance Affinity 4WD Insurance 4WD Vehicle Insurance Comparison Feature Existing Lumley Benefit Standard CGU Benefit CGU Affinity 4WD Benefit Replacement Vehicle If the Vehicle is a Total Loss within 3 years of

More information

VW Camper Van Hire, Pembrokeshire, Wales. Booking can be arranged through the website, email, or telephone call.

VW Camper Van Hire, Pembrokeshire, Wales. Booking can be arranged through the website, email, or telephone call. Terms and Conditions of Hire Our aim is to provide customers with a vehicle in prime condition so you can have the best, relaxing holiday you wish for. Here are our terms and conditions of hire. Booking

More information

Children and Family Services

Children and Family Services Children and Family Services Foster Carers - limited coverage for property loss or damage, personal injury or third party damage or injury Child Protection Services is committed to the support of foster

More information

This section applies to you if the Accident was not your fault and you have been provided with a replacement vehicle.

This section applies to you if the Accident was not your fault and you have been provided with a replacement vehicle. PAA Scheme - Terms & Conditions Accident Not Your Fault? In the unfortunate event of you having an accident that was not your fault, we ll get your vehicle recovered from the accident scene (if it s not

More information