Motor Vehicle Claim Advice Form Page 5
Download a blank fillable Motor Vehicle Claim Advice Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Motor Vehicle Claim Advice Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5Motor Vehicle /
CL AIM ADVI CE FOR M
PART M: DECLARATION AND SIGNATURE
I declare that:
1. AUTHORISE NZI TO MOVE THE VEHICLE TO A CLAIMS ASSESSING CENTRE FOR EXAMINATION AND ASSESSMENT.
2. MATERIAL FACTS
(a) All information given to NZI in connection with this claim (whether oral or written) is true and correct;
(b) No information relevant to the claim is omitted.
3. USE OF INFORMATION
(a) My personal information collected by NZI in connection with this claim may be:
(i) disclosed to other members of the insurance industry and Insurance Claims Register Limited;
(ii) disclosed to parties repairing or replacing the subject matter of the claim;
(iii) disclosed to parties who have a financial interest in the subject matter of the policy;
(iv) used by NZI to advise me of its other services
(b) My personal information held by any other parties in connection with this claim may be disclosed
to NZI;
Please note:
`
`
We gather information about you (including your claims history) to consider your claim. The terms of your insurance policy require
you to supply this information, and if you do not to provide it, or if you provide any false or untrue information, we may decline
your claim.
`
`
Your claims history is passed onto, and held by, Insurance Claims Register Limited. This enables other insurers you deal with to access
it, and prevents fraudulent claims.
SIGNED BY THE DRIVER
Signature
Date
ON BEHALF OF ALL APPLICANTS Signature
Date
PAGE 5
NZI MOTOR VEHICLE Claim Advice Form NZ3403/11 03/15
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal