Stolen or Burnt Vehicle - Kiwibike Motorcycle Insurance
Contents
1. E oid NAA NA E EA Justice of the Peace Solicitor Registrar or Deputy Registrar of High or District Court a person authorised by Section 9 of the Oaths and Declarations Act 1957 Pursuant to the PRIVACY ACT 1993 the following is brought to your attention 1 This claim form and any further enquiries we make of you in order to consider your claim is the collection of personal information about you 2 The information is collected to evaluate your claim 3 The intended recipient of the information is Allianz New Zealand Limited 4 The information is being collected and held by PROTECTA Insurance New Zealand Limited of PO Box 37 371 Parnell Auckland 5 The collection of this information is required pursuant to your insurance policy and is mandatory 6 The failure to provide this information may result in your claim being declined or your insurance being void from the beginning You have rights of access to and correction of this information subject to the provisions of the Privacy Act 19932. ee ee T address nS aera elas E asada ces E a tas N TE TaD ST E vNTAe an sa sa dues cage E eee ona dea Pade ae ee Tae occupation Solemnly and sincerely declare on behalf of all insured s that a all information given in connection with this claim whether oral or written is true and correct and b no information relevant to the claim has been withheld AND make this solemn declaration conscientiously believing the same to be true and by virtue of the Oaths and Declarations Act 1957 e WE authorise the disclosure to Allianz New Zealand Limited of personal information held by any other party regarding any previous insurance of whatever kind or any previous claim under such insurance or any matter Allianz New Zealand Limited may reasonably regard as relevant to my our insurance or any claim made under this insurance e _ I WE authorise Allianz New Zealand Limited to release to other parties any information which Allianz New Zealand Limited holds relevant to my our insurance or any claim made under this insurance e _ I WE authorise Allianz New Zealand Limited to use personal information that it obtained in connection with this insurance or any claim on this insurance for any other purpose in respect of which this personal information may be relevant DECLARED atraia tig iw a eae id iSe dese see eck Cay Of iiaei ani yea oiiaii Signature of All Insureds lt a aa a aaa E a AE AEAEE aaa Aa ea aaa an aSk B TONG ING EE EA
3. PROTEGTA Stolen or Burnt Motorcycle Claim Form Allianz In this claim form we are collecting information to enable us to evaluate your claim Under the Privacy Act 1993 we are required to inform you about certain rights and obligations relating to the information which we are collecting This is in the declaration at the end of the form We recommend that you read it before continuing e The issue of this form does not constitute an admission of liability and is issued without prejudice e Please return this form promptly and make sure that all questions are fully answered e No liability is to be admitted to a third party e No repairs are to be done without our permission e If you receive any communication in any way connected with the loss please forward to us immediately Please return this completed form to PROTECTA Insurance New Zealand Limited PO Box 37 371 Parnell Auckland Or by facsimile to 09 915 7831 POLICY NUMBER cccccssesesssceeceseeesnseenssseeeeseenenennsees RRT Ts Nameoflnsured cs 2c 2o2icccccst ete ede alee ccneelwcdcgdencet sezesees preg Eiin aa Ee aaraa beeddasebeteideiev westecteeataiewneseeleetees ales 2 Postal Address visiere ne aay eves need haves deae hastens age sedheeianitdieg Lie et 3 Contact Phone No Home ccecscceeeeneeeeeeeeeeeeeneeeeeseees Contact Phone No Work cccesseeeeeeeseeeseneeees A Alternative contact ciccc
4. QO IF ANY ANSWER IS YES PLEASE ATTACH FULL DETAILS ON A SEPARATE PIECE OF PAPER P RIDERS Licence Number cccceeseeeeeeeeeeeeeeetteeeeeeees Learner O Restricted O Full O Date Issued LICENCE Classes Any Special Licence Conditions Kae 1 Make oianetan anaram rantaa arat aaaea o E Eo oU Ia E E E E RG E E E VEHICLE 2 Model oo eee eeeeeeeeeeseeeeeeeeeseeeeeeeeees 10 Engine Ratingi se cectcsectasenseseeseatecussnacteces chessaeravebsstetecssereneebereeas 3 VOAR shorii eea E NE 11 Engine Type Carburettor O Fuel Injected O Turbo Charged O 4 Mileage ace csicceescbdesteendecceaeepteteieagneceassace 12 Transmission Manual O Automatic O 5 Registration Number eeeeeeeeeees 13 Japanese 2 7 Hand Import Yes O No O 6 Vin INUMBDEOFS veiecei case aaeeceastiee se eeeteaptas 14 Has the vehicle been modified from the manufacturer s 7 GWassiS ssscscvcdliiic endian standard design or specification Yes O No O 8 Engine Number ee eeeeeeeeneeeeeees If Yes to question 14 please give details 22 2 2 ccc eceecceeeeencce essence eeeeeeenessaseeeeseeeeeeaaeeeeessaeeeseseesesenseeeeeseeseneeeeeenenen es F OWNERSHIP AND FINANCE G HOW THE LOSS HAPPENED H POLICE REPORT I USE AND GENERAL CONDITION J WHEELS AND TYRES 1 Who is the Registered Owner on the Vehicle Ownership Papers 2 Is the vehicle subject to any Hire Purchase o
5. eaeeesaeeeaaeeseaeesaeeseaeeseeeeeeseeeeeieeeeneeees 3 Do you have copies of your servicing invoices accounts Yes O No O 4 Did the vehicle have a current Warrant of Fitness Certificate Yes O No O If Yes where was the WoF obtained cceeeeeeeeeeeeeeeeeeeeees When does the WoF expire c0ceee 5 Did you vehicle need extra oil between services Yes O No O If Yes how much every 1 000 KM cceee oe each month ccce each petrol fill 2 6 Did your vehicle run well Yes O No O If No please give details of any problems cere 1 Is there any other information which would help us with your claim Yes O No O If Yes please give CetallS E e daeehnacsadetateeceeedisig a aE a a aa aaa rra aaa a a a AE E aaia 2 Please tick any of the following documents you can give us and supply them with this form Ownership Papers O Latest Warrant of Fitness Check Sheet O Service Manual O Receipts for Servicing O Owner s Manual O Other O please give details 0 eceeecceeceeeeeeeeeeeeeeeeeeeeeeeeeeeaeeeeeeeseeeseneeesieeeeneeesieeeeneeee P STATUTORY DECLARATION e This is a statutory declaration under the Oaths and Declarations Act 1957 It is a criminal offence to sign this declaration knowing that any of the statements you have provided are not true e t must be witnessed by one of the people listed below icv AVE A ese ee ese ee E E E EA full name Ol ed
6. g Wheels or Other please give details K VEHICLE ACCESSORIE S L KEYS M RECOVERY N SERVICE HISTORY O OTHER DETAILS 1 Were there any other accessories fitted to your vehicle at the time of the loss Yes O No O It Yes please give delde e aa T a a a Aa E a aaa a apes a Ea E AEE a E aaan 1 Do you have the keys for your vehicle Yes O No O _ if Yes please give the serial numbers below IQNILION lt i cee ea eel Fuel Cap rinig iriennou I No whererare they oct E ots etches ck tie ites eh hs See oles teeta to ob ote oe ee 2 Did anyone else have keys to the vehicle Yes O No O If Yes please give their details name address contact phone 3 Did anyone else regularly use the vehicle but not have a set of keys Yes O No O If Yes please give their details name address contact phone 1 Has the vehicle been recovered Yes O No O If Yes 2 When was it found 3 Where was it found 4 Who found it 5 Where is it now 6 Is it damaged Yes O No O If Yes details 7 Have any accessories been removed Yes O No O If Yes details 8 Have you any suspicions as to who the offender might be Yes 0 No O If Yes details 1 Who did the last service on the vehicle 0 2 cceescceceseeeeeeneeeseeeeeeeesneeeesstaeeeesaes Date Terasa pre 2 Where was your vehicle Usually serviced eeeeeceeeeeeeeeeeeeeeeeeeeeeeeeeeseeeseeee
7. isancs ccdiccneyineceddna cs e e aa aE Paaa a Ea ea R Kaa a Ea Ta aaa EEA ENSEN BePETALS 1 What is Date of Birth of the rider or last person to use the vehicle assecc Female O Male O OF RIDER 2 Was this the person shown under Part A Yes O NoO OR LAST If the answer is Yes please go straight to Part C If the answer is No please answer questions 3 8 PERSON 3 iF UlliNe imies sire E E c ssc E scbvcneraie feces sdosesssasdpaiadedivanases vadns cous docesy secon E T A T TOUSE 4 Postall Address a Er e aa a aTe aa a aaa aa aT ar aa a aaar aaa a a E eaa aa dacestaeddedeneacessstadabeeasicd VEHICLE 5 Best contact Phone NO ccccsecceeeeseeeeeeeneeeeesneeeeseneeeeeees Best time to contact sseseseneeeseeenrnrneeeerrrrrreeeerne 6 Relationship to the Insured Husband O Wife O Son O Daughter O Other O give details 7 Did the rider have the owner s permission to use the vehicle Yes O No O 8 Does the rider have any motor vehicle insurance Yes O No O RIDERS 1 Inthe past 5 years has the rider or last person to use vehicle HISTORY a been involved in a motor accident yes O No O b been convicted of a driving offence including speeding or issued with an offence notice Yes O No O c been disqualified from driving or had their licence endorsed cancelled or suspended yes O0 No O 2 Has the rider ever been refused vehicle insurance or had a policy cancelled or not renewed Yes O No
8. r any other finance arrangements Yes O No O If Yes please give full details include the contact address of any finance company etc 3 Who has the ownership papers c 2ccste ieee evils teed eee cd eee veep ae rardi eei 4 When did you buy the Vehicle 2 eee nnne eii ansaa ie a aa aeoea aa aae s aiae aara a a aTa 5 W o did you buy ittrom ooe a eA aS atl ee a aa a a eee ik ade ee eee a 6 How much did you pay for it 00 00 eeeeeeereeeeeees How much was your deposit aseeseen 1 When did you last see the vehicle Day 0 Date isch HUNG oresdee teat esititeece AMO PMO 2 Where did it happen Street and town ccceeeceeeeeeeeeeeeeneeeeneeeeaeeeeaeeeeaeeeeaeeeeaeeeeaeeseaeeseaeeseaeeeeaeessaeeseeeeseaeeneaeesaas 3 Where was the vehicle parked garage carport driveway parking area roadside car park other What purpose was the vehicle being used immediately before the OSS cccssseceeeseeeeeeeeeeeeeeeneeeseeneeeessneeees 5 Were all the doors locked and the windows closed Yes O No O 6 Where were the keys to the vehicle when the theft occurred 7 Where are all the sets of keys now 8 When did you discover the theft had occurred 9 Was the vehicle stolen or parts only 10 If parts only please give details 11 Does the vehicle have an alarm immobiliser fitted Yes O No O 12 If yes make model no 13 If Yes to question 11 was the alarm immobiliser activated Yes O No O 1 Ha
9. s the loss been reported to the Police Yes O No O If No it must be reported to the police and question 2 answered 2 Isa Police Complaint Acknowledgement attached Yes O No O If No please complete the details below Reported Dynesen gi at Station NaMe erneten iraan e esena i ON y araar Complaint Ref NO eececceeseeeeeseeeetees Name of Attending Officer eeseeeeeeeee 1 What was the vehicle mainly used for Private O Business O 2 Was the vehicle already damaged before the loss or theft happened yes O No O If Yes please give details of existing damage 0 0 0 ee eeseeeeeeneeeeeeneeeeeeaeeeeeeaeeeeseaneeeeeeaeeeeeeaaeeeseeeeeeeeaeeeenenaeeeeeaaes 3 Please give a brief description of the condition of each of these eg good average for age poor etc Enginen sie ce A en es PaintWork os cee alii eee A Sis eee Gearbox nioa a a a ks SO ats E EE SE E A TraNSMiSS ONn 000 eeeeeeeeeseeeeeeneeeteneeeeeteneeeeeaes SUSPENSIONY cia Gee eke et ed a LU ee Steering iosi Heese see tis eg eet eee Body Areas iii inti Geert oe eel ea viet i 1 Tyres Please give details for each tyre Date Purchased New or Used Approximate Km Travelled Front gt I Se Ssesebcatalacticaesesthec ett ed Bot de ade tecccascusc Oae rae ee A ea EREE SS Rear l lctiseirestiean tetas tbalt Nesiesh ete wens ceewi shite teed y a cote a eet ares 2 What type of wheels did the vehicle have Manufacturer s Standard O Mag Wheels O Other O If Ma
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