House and Contents Claims Form - PDF Templates

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Home and Contents Claim Form

Unfortunately the unexpected does happen!

This form collects personal information about you so that the insurer can evaluate your claim. Failure to provide this information may result in your claim being declined. The collection of this information is required as part of the terms of your insurance policy. It will be held by, your Appointed Brokerage and the insurer who received your claim. You have the rights of access to and correction of this information subject to the provisions of the Privacy Act 2020. Please visit our website to view our full Privacy Statement.

Your Insured Name And/Or Company Name

testing

Contact Details

First Name

Samanalie

Last Name

Perera

Policy Number

2134567u8i987

E-mail

samanalie@cognitiv.co.nz

Address

Address number

acity name, 0987

Phone Number

(021) 170-2732

Claim Details

When did this happen?

Thursday, October 17, 2024 15:20

Did this incident occur at Street Address: Address number
City: acity name
Postal / Zip Code: 0987
?

Yes

Please provide details of the incident

whoopsie

Were there any witnesses?

Policy Details

General Questions

Do you have any other insurance which covers this loss or damage?

Are you the sole owner of the lost or damaged property?

Yes

Is any of the lost or damaged property subject to any financial or hire purchase agreement?

Who occupies the property?

Owner

Have you claimed on any type of property insurance in the past 5 years?

Have you or any member of your family ever had an insurance claim declined?

Have you or any member of your family living with you, ever been charged or convicted of any criminal offence other than driving offences?

Have you ever had

an insurance polic

y declined, or had

special terms imp

osed?

Details of Claimed Items

Do you have a Schedule of Loss to attach?

Yes

Please upload a copy

PDF

Samanalie-Perera_MotorClaimsForm.pdf

To support ownership and the amounts claimed, please attach receipts, valuations, guarantees, current quotations or other documents.
If repairs have been paid for, please attach a receipt or account.
Wilful or reckless exaggeration of any amount claimed will forfeit the claim.
If at all possible, keep damaged items available so that we can inspect them if needed.

*If item is secondhand, state the item age when obtained.

Declaration

I/We declare that to the best of my knowledge the details provided in this claim form are true. I/We have not withheld any information likely to affect the insurers consideration of the claim.

I/We agree to the appointed insurance brokerage and the Insurance Company (and/or their agent) with whom I am insured may disclose my/our personal information regarding this claim to:

Other parties including other members of the Insurance Industry and the data base of the Insurance Claims Register (ICR Ltd) PO Box 474, Wellington where it will be retained and made available to other insurance companies to inspect.
Parties who have a financial interest in the subject matter of the policy and parties repairing or replacing the subject matter of the claim.
I/We understand that I am/we are entitled to have certain rights of access to and correction of the personal information held by the appointed adviser and the Insurer and ICR Ltd.
I/We understand that my/our personal information may be provided to overseas third party service providers and/ or Insurers who may use this information either on our behalf or otherwise to process and evaluate the claim.

I/We agree to the appointed insurance brokerage and the Insurer obtaining personal information about me/us that is, in their view, relevant to this claim.

From any other party including other members of the Insurance Industry and from Insurance Claims Register Ltd (ICR) which holds details of claims made by me/us under policies with other insurers.

All information and answers (whether written or oral) given to the appointed adviser and the Insurance Company in connection with this claim are correct and that no information relevant to the claim has been omitted. I/We authorise the appointed brokerage and the Insurance Company to act on my/our behalf.

I Samanalie Perera am completing the declaration

Yes

Position

Owner

Date

Thursday, October 17, 2024 15:20

Signature