Form 451 - Claim Form Page 2
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1
2Schedule of claim
Full description
Date originally
Where bought, or, if a present,
Original
Replacement Amount
of articles
bought/received
name and address of giver
cost
cost
claimed
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It is essential that this form be returned promptly to the National Claims Centre.
Pursuant to the Privacy Act 1993
The following is brought to Your attention:
(a) This claim form collects information about you;
(b) The information is collected to evaluate your claim;
(c) The intended recipient of the information is Lumley General Insurance (N.Z.) Ltd;
(d) The information is being collected and held by Lumley General Insurance (N.Z.) Ltd of PO Box 2426, Auckland;
(e) The collection of this information is required pursuant to the terms of your insurance policy;
(f ) The failure to provide this information may result in your claim being declined;
(g) You have the rights of access to and correction of this information, subject to the provision for the Privacy Act 1993.
Declaration
I/We declare that:
(a) The information given in this from is correct.
(b) I/We agree that, should there be any dispute over payment of this claim, Lumley General Insurance (N.Z.) Limited shall be entitled to submit the
dispute to arbitration.
(c) I/We authorise and request the New Zealand Police to release to Lumley General Insurance (N.Z.) Limited copies of any or all documents held by
the New Zealand Police relating to the incident giving rise to this claim. If necessary this authority should be treated as a formal request pursuant
to the Official Information Act, 1982.
(d) I/We authorise the disclosure of personal information held by any other party regarding this claim.
(e) I/We agree to Lumley General Insurance (N.Z.) Limited releasing to other parties personal information regarding this claim.
(f ) I/We authorise the Insurer or its authorised agent to give or obtain from other insurers or other parties any information relating to any insurance held
or claim made.
Note: Failure to provide full and correct information could result in your claim not being accepted by Lumley General Insurance (N.Z.) Limited.
Insured’s signature (if company, state position):
Date:
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Please retain damaged goods in case inspection is required. Please attach estimates in support of repairs as appropriate.
Form 451 03/04
Page 2 of 2
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