Vehicle Claim Form

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.

Part A: The insured
Name*

First NameLast Name
Policy Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number

Area CodePhone Number
Mobile Number

Area CodePhone Number

Part B: Bank account details
If your claim is accepted and you wish to be paid direct to your bank account please complete the following:
Bank Account Details
Please complete as follows: xx-xxxx-xxxxxxx-xxx

Part C: The insured vehicle
Year
Make
Model
Reg Number:*
Is the vehicle subject to a finance arrangement of any kind?

YesNo
Please give details re the arrangement
Has the vehicle or engine been modified from the maker’s standard specifications?

YesNo
Please give details of the modifications
Is a special license endorsement (besides class 1) required to operate this vehicle?

YesNo
Please give details of the endorsements
Is there any other insurance on the vehicle or accessories?

YesNo
Please give details of the other insurance

Part E: Driver's History
Has the driver ever been refused vehicle insurance or had a policy cancelled or not renewed?

YesNo
Has the driver been in a motor accident in the past 5 years?

YesNo
Has the driver been convicted of a driving offence or issued with an offence or infringement notice (including speeding) in the past 5 years?

YesNo
Has the driver been disqualified from driving or had license endorsed, cancelled or suspended in the past 5 years?

YesNo
If you answered ‘Yes’ to any of the questions above, please provide details below:

Part H: Sketch plan of accident
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
Please upload your sketch here:

Browse Files

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Part I: Damage to the insured vehicle
Did the vehicle need to be towed?*

YesNo
Name of the towing company
Name & phone number of repairer*
Address of the repairer

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
When is it to be taken to the repairer?*
Repairer's estimate $

Part J: Other vehicle or property damage
Were other vehicles damaged?*

YesNo
Name of the other vehicles driver*
Their phone number*
Their address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Their insurer and branch*
Other vehicle: Make and model
The other vehicles registration number?*
Please provide full details to other vehicle
Was property damaged?*

YesNo
Details of damage to other property*
Owners name, address and phone number

Part K: Liability for the accident
Did anyone get hurt in the accident?*

YesNo
Please advise who, their relationship to the driver and known extent of their injury
Who do you consider to be to blame?
What are your reasons?
Did anyone admit liability?*

YesNo
Who admitted liability?
Did the Police attend the accident?*

YesNo
Please give police officer's name and number
Have the Police laid or mentioned about laying charges against the driver of your vehicle?*

YesNo
Do you know what the charges are likely to be?

Part L: Witnesses to the accident
Were there any witnesses?*

YesNo
1. Full Name

First NameLast Name
1. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
1. Phone Number

Area CodePhone Number
1. Were they a passenger?

YesNo
2. Name

First NameLast Name
2. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2. Phone Number

Area CodePhone Number
2. Were they a passenger?

YesNo

Part M: Declaration and signature
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.
The drivers name*

First NameLast Name
Signed by the driver*

Clear
Today's Date

DayMonthYear
Date
Name of insured*

First NameLast Name
Signed on behalf of all insured's*

Clear
Today's Date

DayMonthYear
Date
Should be Empty: