General Claim Form

A. The Insured

B. The Loss or Damage

C. Burglary / Theft

D. General Questions

E. The Property lost or damaged

• To support ownership and the amounts claimed, please attach receipts, valuations, guarantees, current quotations or other documents.
  

• If repairs have been paid for, please attach a receipt or account.
  

• Wilful or reckless exaggeration of any amount claimed will forgeit the claim.
  

• If at all possible, keep damaged items available so they can be inspected if needed.
  

F. Declaration and signature

I declare that:

• 1. Material facts

  (a) All information give nto Tasman Insurance Brokers Ltd in connection with this claim (whether oral or written) is true and correct.

  (b) No information relevant to this claim is omitted.

• 2. Use of information

  My information collected by Tasman Insurance Brokers Ltd in connection with this claim may be:

  (i) disclosed to other members of the insurance industry and Insurance Claims Register Limited 

  (ii) disclosed to parties repairing or replacing the subject matter of the claim

  (iii) disclosed to parties who have a financial interest in the subject matter of the policy

  3. My personal information held by any other parties in connection with this claim may be disclosed to the insurer.

• Please note

  The insurer will gather information about you (including your claims history) to consider your claim. The terms of your insurance policy require you to supply this information, and if you do not to provide it, or if you provide any false or untrue information, your claim may be declined.

  Your claims history is passed onto, and held by, Insurance Claims Register Limited. This enables other insurers you deal with to access it and prevents fraudulent claims.