Indicate: Layout of road, Position of vehicles on impact, Road signs and markings, Direction of vehicles travelled, Other vehicles (reg), Identify your vehicle
only accept zip, pdf, jpg, png
Accepted file types: pdf, zip, jpg, png.
PURSUANT TO THE PRIVACY ACT 1993
To be completed by the insured(s) shown and also on behalf of any other person covered by these insurances.
- I/We declare that all information contained in this form and on any attachments is complete and correct;
- I/We have disclosed all information relevant to the acceptance of this proposal;
- I/We agree that this proposal shall be the basis of the contract between me/us and Star Underwriting Agents Limited and I/We am/are willing to accept the terms, conditions, and exclusions for these insurances;
- The sums insured represent the full value of the property insured;
- I/We understand that this proposal request personal information about me/us which is held by Carsure Underwriters, Star Underwriting Agents Limited and Vero Insurance (N.Z.) Limited to evaluate my/our application for insurance. Failure to provide the information sought may result in my/our application being declined or my/our insurance being void from the beginning;
- By signing this form I/We authorize Carsure Underwriters, Star Underwriting Agents Limited and Vero Insurance (N.Z.) Limited to;
- Check details against the Insurance Claims register and to place information on the Insurance Claims Register which other insurers can access;
- Disclose personal information to other members of the insurance industry and/or parties who have financial interest in the subject matter of this insurance;
- Obtain personal information held by any other party regarding my/our existing and previous insurances;
- I/We understand that there are rights of access to and correction of information held by Carsure Underwriters, Star Underwriting Agents Limited, Vero Insurance (N.Z.) Limited, and the Insurance Claims Register.
Declaration:
I/We declare that:
The information given in this form to be correct.
I/We agree that, should there be any dispute over any payment of this claim, Star Underwriting Agents Limited and Vero Insurance (N.Z.) Limited shall be entitled to submit the dispute to arbitration.
I/We authorize and request the New Zealand Police to release to Carsure Underwriters, Star Underwriting Agents Limited and Vero Insurance (N.Z.) Limited copies of any or all documents held by the New Zealand Police relating to the incident giving rise to the claim.
If necessary this authority should be treated as a formal request pursuant to the Official Information Act, 1982.
I/We authorize the disclosure of personal information held by any other party regarding this claim.
I/We agree to Carsure Underwriters, Star Underwriting Agents Limited and Vero Insurance (N.Z.) Limited releasing to other parties personal information regarding this claim.
I/We authorize the Insurer or its authorized 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 Carsure Underwriters, Star Underwriting Agents Limited and Vero Insurance (N.Z.) Limited.