Earthquake - Supplementary Property Information Form

Name owner 1

First NameLast Name

Name owner 2

First NameLast Name

Address

Technical Category (TC) of Land on which this property is situated (for Christchurch properties only)

Find the Category here https://mylandzone.canterburymaps.govt.nz/#/

When did you purchase this property?

DayMonthYear

Please detail the damage that occurred at this property (to the Home and/or other structural improvements to the Land). If the Home is built on a concrete pad, you must specifically detail the extent of the damage to the concrete pad.

Who was the insurer (other than the EQC) at the time of the damage?

Insurer

What was the policy number?

Has the EQC and/or the Insurer accepted a claim for the damage?

Has the EQC and/or the Insurer agreed to carry out repairs?

Has the EQC commenced repair work?

When are repairs (organised by EQC) due to or have been completed?

DayMonthYear

Has the Insurer commenced repair work?

When are repairs (organised by the Insurer) due to or have been completed?

Who carried out the repairs? Please tick

EQCInsurerProperty ownerOther

Is there any unrepaired damage to the Home and/or other structural improvements to the Land?

Has the Owner (past or present) received or opted for a cash settlement from the EQC or the Insurer?

Has the Owner (past or present) carried out or organised to carry out any of the repairs to the Home/Land themselves?

If you have purchased the Home (that existed at the time of the Earthquake events), have you discussed or agreed with the previous Owner that you will receive any funds from any insurance claim made by the previous Owner?

If you answered ‘Yes’ to Question 15, please provide full details of the discussion/agreement below. If you have a written agreement, please send a copy to george@tgn.co.nz

Please read the following Notes, then the Duty of Disclosure and Declaration that follows, before signing and dating this form.

IMPORTANT NOTES

• We reserve the right to ask further questions or require additional documentation in support of your request for cover with Vero.
• If your home is situated on land that has been categorised TC3 (Christchurch), we will require you to supply Building Plans, Geotechnical and/or a Builders Report before further consideration is given to accepting this property for insurance.
• Any uninsured/unclaimed damage that occurred prior to completion of this form will not be covered by the insurance being considered for now.

DUTY OF DISCLOSURE

You are under a duty to disclose all material information to Vero Insurance New Zealand Limited (‘Vero’) whether the information is asked for or not. Material information is information that might influence our decision to insure you and if so on what terms and/or premium. All information given must be complete and correct. If you have any doubt as to whether a fact is material then it should be disclosed.

DECLARATION

I/We declare that the information I/we have provided to Vero within this Supplementary Property Information Form (which is in every respect complete and correct), together with the information also provided in a proposal, application, or declaration form (whether received or provided verbally, electronically, or in printed form) in relation to this property shall be the basis of the contract between me/us and Vero, and I am/we are willing to accept cover subject to Vero’s policy conditions and any special terms they may require.
I/We authorise Vero to give and obtain from other Insurance Companies, Insurance Brokers, the Insurance Claims Register Ltd or any other party any information relating to this or any other insurance held or previously held by me/us and any claim(s) made by me/us.

Signed by Property Owner 1

Owner 1 Date of signing

DayMonthYear

SIgned by property owner 2

Owner 2 Date of signing

DayMonthYear

Before you send this completed form to TGN by clicking the SUBMIT button, please also ensure that you have sent the following documents to george@tgn.co.nz (where applicable):

Scope of Works from EQC and/or Insurer (in all cases)Practical Completion Certificate or other proof that repairs have been completed (if you have answered ‘No’ to question 12)Details of any agreement made between the previous Owner and current Owner (if you have answered ‘Yes’ to question 15)Building Plans (if we specifically ask for this)Geotechnical Report (if we specifically ask for this)Builders Report (if we specifically ask for this)

To get copies of your 'Scope of Works' and 'Practical Completion Certificate' email EQC at info@eqc.govt.nz

OR fill in a Information Authority CLICK HERE and we will do it for you

You will need your EQC Claim Number