Material Damage Claim Form

Material Damage Claim Form
Please complete your claim form so that we can get your claim moving!
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*
Please provide your registered company name if applicable
First Name*
Last Name*
Policy Number
E-mail*
example@example.com
Phone Number*
Area or Mobile CodePhone Number
Insured / Company name cannot contain “,*,:,,?,/,|, Please check your response

Claim Details
Tell us what happened
What is this claim for?*
What happened to the Commercial Building?*
What happened to the Business Contents?*
When did this happen?*
DayMonthYear
Date
Hour MinutesAM/PM Option
Where did this happen?*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Please provide details of the incident*
Have you done anything to reduce or recover the loss or damage?*
YesNo
Actions taken*
Were there any witnesses?*
YesNo
Witness Details*
Do you have a Police Complaint Acknowledgement to attach?*
YesNo
Please attach the Police Complaint Acknowledgement*
Cancelof
Reported by:*
First NameLast Name
Date of report*
DayMonthYear
Date
Station the report was made at*
Complaint Reference Number*
Name of Attending Officer*
First NameLast Name
Do you think that any other person is responsible for the loss or damage?*
YesNo
Reasoning*

General Questions
Do you have any other insurance which covers this loss or damage?*
YesNo
Please provide details*
Have you claimed on any type of property insurance in the past 5 years?*
YesNo
Please provide full details (include date, type of claims and name of Insurer)

Declaration
Declaration must be signed by the Policy Holder
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:
1. 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.
2. Parties who have a financial interest in the subject matter of the policy and parties repairing or replacing the subject matter of the claim.
3. 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.
4. 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 {firstName} {lastName} am completing the declaration*
YesNo
First Name*
Last Name*
Position*
DirectorOwnerAuthorised Administrator
Date
DayMonthYear
Date
Hour MinutesAM/PM Option
Signature*
Clear
Should be Empty:

Material Damage Claim Form

Claim Details

General Questions

The Property Lost or Damaged Details

Declaration