CARSURE Motor Claim Form

INSURED DETAILS: FULL DETAILS OF INSURED/OWNER

Insured/Owner*

Client and policy numbers*

Postal address*

Suburb/Town*

If company, contact name

Position

Telephone No:

Home*

Mobile

Work

Email address*

Fax No

VEHICLE DETAILS: FULL DETAILS OF INSURED VEHICLE

Year*

Make*

Model*

Reg No*

Financially interested/leased*

YES
NO

DRIVER DETAILS: FULL DETAILS OF INSURED DRIVER OR PERSON IN CHARGE OF INSURED VEHICLE AT THE TIME OF ACCIDENT OR LOSS

Full name*

Date of birth*

Home adress*

Suburb/Town*

New Zealand licence*

Yes
No

Years licenced*

Type*

Learner
Restricted
Full

Licence No*

Version No*

Expiry date*

Classes covered:

Relationship to insured*

Insured/Owner/Director
Relative (specify)
Other (specify)

For what purpose was the insured vehicle being used?*

Business
Private

Had you taken any intoxicating liquor and/or drugs (prescribed or otherwise) within the 12 hours prior to the accident?*

Yes
No

If yes, please give full details:

Have you ever been convicted of any traffic or criminal offences (other than parking) within the last five years:*

Yes
No

If yes, please give full details:

Offence

Approximate date

Court action

Have you had any motor accidents or claims including theft (other than windscreen breakage) within the last five years?*

Yes
No

If yes, please give full details:

Details

Approximate date

ACCIDENT/LOSS DETAILS:

Location (street)*

Suburb/town*

Date*

Time*

: HH

MM

Day of week*

Speed (kmph) prior to braking

Approximate speed (kmph) on impact

Road surface*

Sealed and dry
Sealed and wet
Unsealed and dry
Unsealed and wet

Weather conditions*

Vehicle activity*

Was any warning (horn signals etc) given by any person?*

Yes
No

If Yes, please give details

Were your headlights switched on and functioning?

Yes
No

Do you consider the other driver was responsible for the accident?*

Yes
No

If Yes, please give reasons

Describe in detail how the accident occurred*

DETAILS OF DAMAGE OR LOSS TO INSURED VAHICLE

(INDICATE WHERE INSURED VEHICLE IS DAMAGED)*

Where can the insured vehicle be inspected?*

Have you sent it to be repaired?*

Yes
No

If Yes, please give name of repairer

Contact phone

Have you obtained an estimate for repairs?*

Yes
No

If Yes, please advise amount of estimate

Estimate $

Has Carsure Underwriters Ltd been contacted regarding the loss and/or have been we given the opportunity of appointing an independent assessor or loss adjuster (if required)?*

Yes
No

If Yes, please give details:

Were there any passengers in insured vehicle?

Name	Address	Telephone No

WITNESSES

It is important that names & addresses are obtained whether the driver considers him/herself to blame or not

Name	Address	Telephone No

SKETCH PLAN OF ACCIDENT (NOT REQUIRED FOR THEFT OR FIRE CLAIMS)

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

OTHER PROPERTY: FULL DETAILS OF DAMAGE TO OTHER DRIVER VEHICLE OR PROPERTY
Property or vehicle owned by:

Vehicle make*

Model*

Reg No*

Driver full name*

Contact address*

Suburb/town*

Contact telephone No, Home

Work

Mobile

Their insurance company

Branch

Estimated cost of repairs to other party's property (if known)

$

If more than one other vehicle involved in accident, please give details

Other driver's full name

Contact address

Suburb/town

Contact telephone No, Home

Work

Mobile

Vehicle make

Model

Reg No

POLICE REPORT

Do the Police have knowledge of this incident?

Yes
No

If Yes, please give details: Name of officer

Number

Address of station

Did the Police attend the scene of the accident?*

Yes
No

Did any driver undergo any test for alcohol or drugs?*

Yes
No

If Yes, please give details

Name	Address

Have the Police issued a Notice of Intended Prosecution, or given any verbal warning?*

Yes
No

If Yes, to whom and for what alleged offence?

Name	Offence

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;
1. Check details against the Insurance Claims register and to place information on the Insurance Claims Register which other insurers can access;
2. Disclose personal information to other members of the insurance industry and/or parties who have financial interest in the subject matter of this insurance;
3. 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.

I have read the declaration on this form and am aware that failure to provide full and correct information could result in my claim not being accepted by Carsure Underwriters, Star Underwriting Agents Limited and Vero Insurance (N.Z.) Limited.*

Yes

Motor Claim Form

Carsure Underwriters Ltd

Step 1 of 4

Personal Information

What sort of car do you have?