Form 451 - Claim Form printable pdf download

Form 451 - Claim Form

claim form

Lumley General Insurance (N.Z.) Limited, Lumley Business Solutions, PO Box 3939, Auckland, New Zealand, Tel 0800 110 088, Fax (09)308 1115

Insured details

Name of Insured:

Claim number (if known):

Policy number:

Expiry date:

Postal address:

Phone number: Home:

Work:

Occupation:

Type of policy:

Details of damage or loss

You must immediately inform the police if property has been lost or if you suspect burglary, theft, arson, malicious damage or any other

criminal act has caused the damage or loss.

Date:

Day of the week:

Time:

am/pm

If Theft/Burglary, between what hours:

am/pm and

am/pm

Where did the loss occur?

Brief description (including cause of loss or damage):

Name and address of person causing damage:

If reported to police, date reported:

Name of police station:

(Attach police acknowledgement form)

Amount claimed (as shown on the Schedule on reverse side of this form): $

Other particulars

When was the loss discovered and by whom?

If Theft/Burglary, how was entry to the premises affected and was any damage caused gaining entry?

Were the premises occupied at the time of loss?

Has any arrest been made or is anybody suspected of the theft or any other crime?

Has any of the property been recovered?

If the premises are not owned by you does the lease make you responsible for repairing any damage?

Are you the sole owner of property damaged or stolen? Yes

If No, please name any other interested party (e.g. mortgagee, trustee etc.):

Name:

Branch:

Details of other insurances covering the property claimed for:

Have you had a loss or made a claim against any Insurance Company in the past 5 years (regardless of the amount), or ever had a loss exceeding

$5,000? (If so, please supply details including Insurer’s name.)

Please return this form promptly to the Company with all questions on both sides fully answered. If any question is not applicable, state “N/A” .

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Form 451 - Claim Form

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