Motor Vehicle Claim Advice Form Page 2
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5Motor Vehicle /
CL AIM ADVI CE FOR M
4. Relationship to the Insured:
Husband
Wife
Son
Daughter
Other
(give details)
5. Did the driver have the owner’s permission to use the vehicle?
Yes
No
6. Does the driver have any motor vehicle insurance?
Yes
No
7. Does the insured confirm ownership?
Yes
No
PART E: DRIVER’S HISTORY
1. Has the driver ever been refused vehicle insurance or had a policy cancelled or not renewed?
Yes
No
2. In the past five years has the driver:
(a) been involved in a motor accident?
Yes
No
(b) been convicted of a driving offence or issued with an offence or infringement notice (including speeding)? Yes
No
(c) been disqualified from driving or had license endorsed, cancelled or suspended?
Yes
No
If you answered ‘Yes’ to any of the questions above, please provide details below:
PART F: DRIVER’S LICENCE
Full name as it appears on driver’s licence:
Surname:
First name(s):
Date of birth (field 3 on licence):
Licence issue date (field 4a):
Licence expiry date (field 4b):
Full address as it appears on driver’s licence (field 6):*
*This field is optional and may be blank on your licence
Driver’s licence number (field 5a):
Licence version number (field 5b):
Licence classes / endorsements: (field 7):
Classes / endorsements for conditions (field 9):
Was the driver licensed to drive this class of vehicle under the conditions endorsed?
Yes
No
1. Number:
Classes: 1
2
3
4
5
or 6
2. Type:
Licence Endorsements: P
V
I
O
D
F
R
T
W
or NIL
3. Date and country of Issue:
PART G: DETAILS OF ACCIDENT
1. When did the accident happen?
Day:
Date:
Time:
AM
PM
2. Where did it happen? (street and town):
3. What was the vehicle being used for?
PAGE 2
NZI MOTOR VEHICLE Claim Advice Form NZ3403/11 03/15
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