Motor Claims Form - PDF Templates

Motor Claim Form

Unfortunately the unexpected does happen!

This form collects personal information about you so that the insurer can evaluate your claim. Failure to provide this information may result in your claim being declined. The collection of this information is required as part of the terms of your insurance policy. It will be held by, your Appointed Brokerage and the insurer who received your claim. You have the rights of access to and correction of this information subject to the provisions of the Privacy Act 2020. Please visit our website to view our full Privacy Statement.

Your Insured Name And/Or Company Details

testing

First Name

Samanalie

Last Name

Perera

Policy Number

P000689256SVU

E-mail

samanalie@cognitiv.co.nz

Insured Vehicle Details

Model

911

Licence Plate

BLJU87654

At the time of the accident was the vehicle being used for business or carrying any goods?

Was your vehicle damaged?

Details of Driver or Person in Charge

Was it the insured driving when the accident occured?

Yes

Address

Address number

acity name, 0987

Date of Birth

Thursday, October 17, 2024

Phone Number

(021) 986-5434356

Type of Licence

Full

Drivers Licence Number

DY987652

Drivers Licence Version

Are you the Policy Holder?

Yes

In the past five years has the driver:

Had any losses / i

ncidents involving

damage or theft o

f a vehicle? (excl

uding glass)

Been disqualified from driving or had license suspended or cancelled?

Been convicted of any offence other than parking or speeding?

Had any insurance refused, cancelled, special terms imposed or had a claim declined?

Incident Details

Date of Incident

Wednesday, October 16, 2024 15:07

Address of the Incident

Address number

acity name, 0987

Were any of the following traffic controls present at the scene of the accident?

	Answer
Stop sign?	Yes
Give-way sign?	No
Traffic lights?	No

If any of the items were present were they in your favour?

Yes

Was the road wet at the time of the accident?

Please describe how the accident occurred

whoopsie hehe

Was the accident your fault?

Please explain

Shit happened

Third-party damage

Were any other veh

icles or property

involved in the ac

cident?

Authorities and Witnesses

Was the accident reported to the Police?

Was any intoxicating liquor and/or drugs (prescribed or otherwise) consumed by the driver in the 12 hours prior to the accident?

Was a breathalyser, blood test or any other test requested?

Were there any other passengers in your vehicle or any other witnesses?

Declaration

I/We declare that to the best of my knowledge the details provided in this claim form are true. I/We have not withheld any information likely to affect the insurers consideration of the claim.

I/We agree to the appointed insurance brokerage and the Insurance Company (and/or their agent) with whom I am insured may disclose my/our personal information regarding this claim to:

Other parties including other members of the Insurance Industry and the data base of the Insurance Claims Register (ICR Ltd) PO Box 474, Wellington where it will be retained and made available to other insurance companies to inspect.
Parties who have a financial interest in the subject matter of the policy and parties repairing or replacing the subject matter of the claim.
I/We understand that I am/we are entitled to have certain rights of access to and correction of the personal information held by the appointed adviser and the Insurer and ICR Ltd.
I/We understand that my/our personal information may be provided to overseas third party service providers and/ or Insurers who may use this information either on our behalf or otherwise to process and evaluate the claim.

I/We agree to the appointed insurance brokerage and the Insurer obtaining personal information about me/us that is, in their view, relevant to this claim.

From any other party including other members of the Insurance Industry and from Insurance Claims Register Ltd (ICR) which holds details of claims made by me/us under policies with other insurers.

All information and answers (whether written or oral) given to the appointed adviser and the Insurance Company in connection with this claim are correct and that no information relevant to the claim has been omitted. I/We authorise the appointed brokerage and the Insurance Company to act on my/our behalf.

I Samanalie Perera am completing this declaration form and have the authority to do so.

Yes

Position

Director

Date

Thursday, October 17, 2024 15:07

Signature