Vehicle Claim Form

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.
THE DRIVER OF THE VEHICLE (OR THE PERSON WHO WAS IN CHARGE) MUST SIGN ‘PART M’ OF THIS FORM.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Area CodePhone Number

If your claim is accepted and you wish to be paid direct to your bank account please complete the following:

Please complete as follows: xx-xxxx-xxxxxxx-xxx

Date

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Area CodePhone Number

First NameMiddle NameLast Name

Date

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

DateHourMinutesAM/PM Option

If the insured vehicle was being driven when the accident happened:

Please attach a sketch to show any:

Street names
Road markings
Traffic signals
Distances between vehicles
Distances from kerb
Road signs
Traffic islands
Direction of travel

Browse Files

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Area CodePhone Number

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Area CodePhone Number

I declare that:

1. I AUTHORISE INSURE TARANAKI TO MOVE THE VEHICLE TO A CLAIMS ASSESSING CENTRE FOR EXAMINATION AND ASSESSMENT.

2. MATERIAL FACTS:

(a) All information given to Insure Taranaki in connection with this claim whether oral or written) is true and correct;

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

3. USE OF INFORMATION

(a) My personal information collected by Insure Taranaki 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;

(iv) used by Insure Taranaki to advise me of its other services

(b) My personal information held by any other parties in connection with this claim may be disclosed to Insure Taranaki;

Please note:
We 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 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.

By signing or marking the below electronic signature or submitting this form you agree to the terms and conditions above and in regards to your claim.

Date