Motor Vehicle Claim Advice Form
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CLA I M A DV I C E FOR M
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We recommend that you read the Claims section of your policy.
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Please answer all the questions on this form. If a question does not apply to your claim, please answer ‘N/A’.
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You must not incur any expense (unless it is to minimise the loss), or admit fault, without our permission.
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THE DRIVER OF THE VEHICLE (OR THE PERSON WHO WAS IN CHARGE) MUST SIGN ‘PART M’ OF THIS FORM.
PART A: THE INSURED
Name:
Policy number:
POSTAL ADDRESS
Number/Street:
Suburb:
Town / City:
Post code:
CONTACTS
Home phone:
Fax:
Mobile phone:
Email:
PART B: BANK ACCOUNT DETAILS
If your claim is accepted and you wish to be paid direct into your account, please fill out the details below:
Bank Account:
PART C: THE INSURED VEHICLE
1. Year:
Make:
Model:
Reg. No.:
2. Is the vehicle subject to a finance arrangement of any kind?
Yes
No
If ‘Yes’, please give details:
3. Has the vehicle or engine been modified from the maker’s standard specifications?
Yes
No
If ‘Yes’, please give details:
4. Is a special license endorsement (besides class 1) required to operate this vehicle?
Yes
No
If ‘Yes’, please give details:
5. Is there any other insurance on the vehicle or accessories?
Yes
No
If ‘Yes’, please give details:
PART D: DETAILS OF DRIVER OR PERSON IN CHARGE
1. What is the driver’s Date of Birth?
Female
Male
2. Was the driver (or person in charge when the accident happened) the person shown under Part A?
Yes
No
If ‘Yes’, please go to Part E, If ‘No’ please answer questions 3 – 6
3. Full name of driver (or person in charge)
POSTAL ADDRESS
Number/Street:
Suburb:
Town / City:
Post code:
CONTACTS
Best contact phone number:
Best time to contact:
PAGE 1
NZI MOTOR VEHICLE Claim Advice Form NZ3403/11 03/15
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