Checklist
Before filling out this form, please check the following:
- You have read the Claims Protocol
- All items for claim are identified (you will add them in the 'Schedule of Items Claimed' section of this form)
- All damage is thoroughly documented and the cause is identified
- All damage is photographed (have your photos ready to upload to this form)
- A Police Report (if available) is to be uploaded to this form
- Reasonable precautions have been taken to ensure no further damage
- If you have obtained quotes for repair or replacement please ensure you attach them to this form
- You are filling out this form with full details of your claim before purchase or repair (an assessor may need to be appointed)
- If you would like to complete a PDF form instead of this online form, download it here. Please email your completed form and any supporting documents to and , as well as to your local insurance manager or broker
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Declaration, Privacy Act, Insurance Claims Register
I/We declare that to the best of my/our knowledge and belief, these particulars are complete and correct.
I/We:
- agree to give any further information that may be required.
- understand that the claims manager requires this information, which may be personal, which will be
retained by claims manager, before they can evaluate the claim.
- authorise the disclosure of this personal information regarding this claim to other parties.
- authorise the obtaining by the claims manager, from any other party personal information about me/us that
is in their view relevant to this claim.
- authorise the obtaining by the claims manager, from Insurance Claims Register Limited (ICR Ltd), which
holds details of claims made by me/us under polices with other insurers, personal information about me/us
that is in their view relevant to this claim.
- authorise the claims manager to place details of this claim on the database of ICR Ltd, PO Box 474
Wellington, where it will be retained and available to other insurance companies to inspect.
- understand that I am/we are entitled to have certain rights of access and correction of the personal
information held by the claims manager and ICR Ltd.
Note that the claim should be settled within twelve months from date of claim acceptance.
The collection of this information is required under terms of the policy. Failure to provide it may result in the
claim being declined.
Please check all fields have been completed then submit your claim below.
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