General Claim Form

General Claim Form
If you need any help with this form, please contact insure Taranaki.
- If you supply any untrue or false information and know that it is not true Insure Taranaki shall have the right to refuse the claim.
- We recommend that you read the Claims section of your policy.
- 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 our permission.

Part A: The Insured
Name*

First NameLast Name
Policy Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Number

Area CodePhone Number
Mobile Number

Area CodePhone Number
Best Time To Contact

:HourMinutesAM/PM Option
Email*
example@example.com
If your claim is accepted and you wish to be paid direct to your bank account please complete the following:
Bank Account Number:
Please complete as follows: xx-xxxx-xxxxxxx-xxx

Part B: The Loss or Damage
Where did the loss or damage happen?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What date did this accident happen?*

MonthDayYear
Date
About what time did this accident happen?*

:HourMinutesAM/PM Option
When did you first know about it?
How did the loss or damage happen? (Please give full details)
Have you done anything to reduce or recover the loss or damage?

YesNo
Please give details:
Were there any witnesses?

YesNo
Please give details:
Do you think that any other person is responsible for the loss or damage?

YesNo
Please give details: