Claims

Motor Vehicle Claim Form

Including boats, trailers, motorhomes.

If you need any help with this form, please contact Tasman Insurance Brokers Ltd. If you supply any untrue or false information and know that it is not true the insurer shall have the right to refuse the claim, as this is classed as a legal statement. Please answer all the questions on this form. If a question does not apply to your claim, please answer “N/A”. You must not incur any expense (unless it is to minimise the loss), or admit fault, without the insurer’s permission.

A. The Insured

Name

Postal address

Phone Number

Insurer / Policy Number

If your claim is accepted and you wish to be paid direct into your account, please fill your Bank Account details

B. The Loss or Damage

1. When did the loss or damage happen?

2. Where did it happen? (Full address or details of the location)

3. When did you first know about it?

4. How did the loss or damage happen? (Please give full details)

5. Have you done anything to reduce or recover the loss or damage?

Yes

6. Were there any witnesses?

Yes

7. Do you think that any other person is responsible for the loss or damage?

Yes

C. Vehicle Details

Vehicle details

Warrant expiry

Rego expiry

Is there any finance on the vehicle?

Yes

Describe the damage to the insured vehicle

D. Driver Details

Full name

Date of birth

Drivers licence number

Please supply a photo of both sides of your drivers licence

What speed was the vehicle travelling at the time of the accident?

Relationship between the driver and the policy holder

Had the driver had any drugs or intoxicating substances 12 hours prior to the accident?

Yes

Did the driver have to undertake any breath or blood tests after the accident?

Yes

Does the driver have any criminal convictions or licence conditions?

Yes

E. Third Party Details

Were any other parties involved in the incident?

Yes

Did the police attend the incident?

Yes

F. Burglary / Theft

1. Does this claim involve burglary, theft, unexplained loss or intentional damage?

Yes

G. Repairer Details

Do you have a preferred repairer?

Yes

Where is your vehicle currently? (in the event that inspection by an assessor is required)

H. General Questions

1. Do you have any other insurance which covers this loss or damage?

Yes

2. Have you claimed on any type of property insurance in the past 5 years?

Yes

I. Declaration and signature

I declare that:

1. Material facts

(a) All information given to 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.

Signed on behalf of all insureds:

Additional files

Add more

Contact

299b Queen St Richmond

Karen Botica

FSP 386146

Director / Commercial Broker

0274843238 [email protected]

Rachael Gunn

Domestic Broker

FSP 1010667

027 4561494 [email protected]

Raquel Chapman

Claims and Broker Support

FSP 1010666

021454953 [email protected]

Megan Holland

Commercial Broker Support / Broker / Admin support

FSP 600990

021 982 763 [email protected]

Motor Vehicle Claim Form

A. The Insured

B. The Loss or Damage

C. Vehicle Details

D. Driver Details

E. Third Party Details

F. Burglary / Theft

G. Repairer Details

H. General Questions

I. Declaration and signature

1. Material facts

2. Use of information

Please note

Contact

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