Home

Classic Stolen or Burnt Vehicle Claim Form

1. Is the vehicle you own insured If VS whieh MSU T oisinn p eeann iedit aain 3 HISTORY OF LAST PERSON TO USE VEHICLE Licence Number 5a Version Number 5b Which Vehicle Classes cesseeceeseeeeeeeeeeeeeeeeeeneeees Issue Date Day Month Year Expiry Date Day Month Year O LEARNER O RESTRICTED O FULL O OVERSEAS O NEVER LICENCED O DISQUALIFIED In the last 5 years has the last person to use the vehicle Had their licence endorsed or suspended Been involved in i any previous accidents or ii suffered any losses If Yes when and what were the losses include accidents or losses which were not claimed under insurance 4 VEHICLE OWNERSHIP DETAILS Is the insured the Registered Owner of the Vehicle Yes Go to next section No Complete this section Title i 2 Other Date of Birth Day Month Year First Name Last Name Company Name Address 5 VEHICLE FINANCE DETAILS a Please advise who has the vehicle ownership papers ss scsicscsriserserecirsieseueeuernssrsreurrettuerurrunvror turene run ttu sentire rA nntu SEE EEA PENE ESSENSEN EENE nE ASSEN NE PEENE ESE EENAA NEEESE ENN anrea Ena b c d e What date was the vehicle purchased Day Month Year Weho was the vehicle purchased from o eee raan en Ea ER AA VaR EANA Ea AARNE ENARA EA ee eb eE AAEE aO AEE EEA A aE ARa AAAA Ea aaaea Aa d
2. a a E escapes E araa A E anaran eA EA O EENE EEEE EEEE T ENEE b What date and odometer reading was the last service done at Day _Month_ __Y ar__ Odometer reading ce eens Km Miles e Whereis your vehicle usually Serviced sic c ccc5 sccseeccck se esese23 sce edad aeee eee pear E aE E n ECE Na aadi aaiae feces sc Slveu vee Kaaa e o Eai ugebesbed cdesteceiaalebes d Do you have any copies of your servicing invoices accounts Yes No e Did your vehicle have a current Warrant of Fitness Certificate Yes No f IE Yes where was the Warrant of Fithess obtalme itis c2s css ceecessses se raine a e na a AEE a aE Eaa ERA E a a ae i LEANE iaeei g9 When does the Warrant of Fitness expire Day Month Year __ h Did you vehicle use extra oil DetWEeN SErvVICES 2 sesecccaceccs osu ce seci ee unset Sede cecsesapeceSbensyapeseesdblteasepeisabecsanzecessusncesesestdbadeeaesbocgsacessh desnustevesscapestis sansstapentseetiecd i If Yes how much oil every 1 000km miles 0 ee Each Month ices ceccssaantccnesneene Each fuel TM occessncseniserecerecceatns j Did the vehicle run well O Yes O No If No please give details of any problems 14 POLICE REPORT a Has the loss been reported to the Police Yes No If No it must be reported to the Police b Is a Police Complaints form attached to this claim form Yes No If No please complete details
3. below c Loss reported by __________ Name_of person that reported loss _______ _ on _Day_ _Month_ __Year___ Se een a ae Name of Police Station ___ to _________________ Name of attending Police Officer _ Complaint Reference No 2 cc2 cicccccee ncccssscisesenenrennscenindenreninenntacsiveedineraueeeereneses 15 OTHER INFORMATION THAT MAY HELP a Is there any other information that you believe may assist us with your claim please provide details here cececeeeeeceeeeeneeeceeeeeeesaeeeseeeeseaaeeseeeaeesneaeeseeeeeees b Please tick any of the following documents that you can provide us and supply with this claim form o Ownership Papers O Latest Warrant of Fitness Check Sheet Service Manual Receipts for Servicing invoices Owners Manual El Other documents Please Give details parsoni e e n sie vale E a R AO a ede aa 16 STATUTORY DECLARATION 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 It must be witnessed by one of the people listed below Wooo Ful name sses i a a a oS a aa ra eea ea e aaee ee eea ROE MCU SS Ya A a a a es Me Atanas Occupation a a cs es a se eee Solemnly and sincerely declare on behalf of all insured s that All information given in connection with this c
4. Cae Stolen or Burnt Vehicle Claim Form We believe customer service is paramount particular at claim time To help us help you please complete this claim form as soon as you are able We understand and support your rights as a consumer If you have any questions regarding the information we are collecting about you please contact our Motorteam or visit the Privacy Commissioner s website http privacy org nz PROTECTA Insurance New Zealand Limited PO Box 37 371 Parnell Auckland Free phone 0800 435 7868 Facsimile to 09 915 7831 j Email motorteam protecta co nz 1 INSURED DETAILS Note If you receive any communication from any party connected with the loss please forward to us immediately Policy Number Title x iss i Other First Name Last Name Address Home Phone Mobile 2 DETAILS OF LAST PERSON TO USE THE INSURED VEHICLE Was the Insured the last person to use the vehicle prior to theft or fire Yes Go to next section No Complete this section Title 5 i Other Date of Birth Day Month Year First Name Address What is your relationship to the Insured Did you have the Insured s consent to use the vehicle If No how did you gain possession of the vehicle Do you regularly drive this vehicle If Yes how often Do you have your own motor vehicle
5. anced What was the purchase price of the vehicle How much was the deposit Is the vehicle subject to any Hire Purchase or any other finance arrangements Yes No f If Yes please provide full details include contact and address details of any finance company etc Version 06052014 6 VEHICLE DETAILS Make amp Model Engine CC Rating Odometer reading at date of loss Km Miles Engine Type O Carburetor O Fuel Injected O Turbo Charged Supercharged Transmission Manual Automatic Tiptronic CVT VININ O einstein eee e a a lccey states earr a cede aaae eE Engine NO ccccisncacncecusd one e EE a dee Chassis NO oaii nai oon aaee E e E cae is EE E apa pete e etateem tate edonaa Unique identitying features of the vehiCle isesrineiesin sects ehatecchecgegnedeecegecenteesnacuaylatesalencogeystesnaten coupasdtduscpadesasesyadencessonen ee ialestenedhen Gasstenuvadseapcclsretnoressdesceenbdogeecegeeegbers 9 ACCESSORIES a Were there any accessories fitted to the vehicle at the time of the loss Yes No If Yes please state value B Please list accessories sarmnieoryin eiers voted e EE ecuees O E E R E beacause nes saee R aa Ra a ie a Ea i 8 VEHICLE MODIFICATIONS WHEELS amp TYRES a Has the v
6. eaeeees 12 RECOVERY a Do you know if the vehicle has been recovered Yes Complete this section No Go to next section What date was the vehicle recovered Day Month _Year__ b Where was the vehicle recovered from or fOUNG ceeeeeceeeececeeeeecee cece ceeneeesenaeeceseaeeceaaeeceseaeeseaaeesesaaeeeeaaeescseaesessaeesnaeae ces caeeseaeaseaeeseseeessceaeeeesieeesseaeeeeeneeeees G W hotound the vehicle T s sinan aerar areena ea Stew cna e Pea Eea ne teen lec oc dove aa ete gt paee sae esc eee cd sce a Ea eiie dioer Nedsaee ea E tees agate age d Where is the vehicle NOW cceceeececeesce cece ceeeececeeeeeeesueeeceaaeeeeaeeeseeaaaeeecaeeseaeeeesaeaeeeeesneaeeseaeeesenes e Is the vehicle damaged O Yes Please describe damage g Do you have suspicions as to who the offender might be O Yes Please provide suspects details Title O Mr O Mrs Miss Ms VOET aaeeei Date of Birth _Day_ Month _Year _ MSE IN ANG cai e eroen EEEE EE Ha A FE Tip E ee E E EE E E EATE E ET E EET AQArOS S oiiire aaa i a Gideon raaa Home PRONG sisng meiiies Work PONG se insconeissnceiciancensmerestianciaiiensiins Asda bebe Sai Medd ceases seuade ae een arenes aes a een cena Stee Mobile anna HEINE ia r e aE 13 SERVICE HISTORY a Who did the lastservice on th vehicle aiie n a aa e aeaee Ea a Ee a TE E TE even Gee
7. ehicle been modified in any way Yes No If Yes please state value 0 eeeeeeeeeteeeeeees BY n Please list MOGitiC ations rires r ea dees bales aa Aa aea aa evade dee aa aA TEE TNA weaved a a ad Aate eaea iaae iA c What type of wheels does the vehicle have O Manufacturer s standard Mag Wheels Other d Hy Other Please COS Crile iisi aenea anra e aa ae ea a e a a E aara aa aaa Ra aE aa Glace EEEa a Ea ea kee eee E aaRS GENE e aeaa 9 VEHICLE CONDITION a Did the vehicle have any existing damage prior to this loss occurring Yes No b If Yes please describe damage c Please give a brief description of the condition of the following components e g New Good Average for Age Poor etc Paintwork creeert aaaeei er ie Gidea Bodywork Chassis Coripe Engine ASE A E E EE EEE ES Leete E ESEN SUSPENSION ennonn Ea Transmission Drivetrain wcssc cii ccesacediceeectaisecessetcassiadsisicnccesinateeecksys UMONSTONY ie eenias aaaea Steering eiei asso evhaenclaeecssamedeeas d Please describe condition of wheels and tyres e g New Good Average for Age Poor etc Left Front Right Front Left Rear Right Rear 10 KEYS LOCKS ALARMS amp IMMOBILISER a Were all the doors locked and windows closed Yes No b Describe where the keys were to the vehicle when the los
8. iser E EE EEA EE E E A A E E E A h If Yes to question f was the alarm Immobiliser activated Yes No 11 DESCRIBE HOW THE LOSS HAPPENED a When was the vehicle last seen Day_ Month Year Time _Hours Mins OAM PM b What was the vehicle being used for immediately before the loss Business Personal Please provide details of the purpose of use c Where was the vehicle last seen parked O Garage O Carport Driveway Road side Parking Area Carpark Other d Where did the loss occur Name the street town City etC eee eeceeeeeeeeceee eee ceeeeeceeeeceeaeeceseeeeceaaeeeesueeeeeeaeeeeeeeeeeeeeetieeeeeees aaoo irai haar eet eels e When did you discover the loss had occurred Day_ Month Year Time __Hours_ _Mins___ AM PM f How did you find outthe loss had OCCUNOO iccs caxceszsesdecectseunssc eee esana Vesgpd casio OSEE E R OR e EEE p sarai ren oiae sat cessagdez sbacadedadeaghsdy seedecregacotezasetinessiusdanesseia sacs g Was the vehicle stolen or parts only stolen O Vehicle stolen Only parts stolen Fire not applicable h If parts only stolen please give details Of stolen parts cee ceecseceeeeceeceeeeeeeeeceeseneeeceaeeeseaeaeeceaeeeeceeeeseaaeessaeaeeeeaaeeesseeeeseaaeeesaeaeeeeaaee ceeeesgaeseeeaeeesseaeeeeeaeeete
9. laim whether oral or written is true and correct and 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 I WE authorise the disclosure to Allianz Australia Insurance 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 Australia Insurance Limited may reasonably regard as relevant to my our insurance or any claim made under this insurance I WE authorise Allianz Australia Insurance Limited to release to other parties any information which Allianz Australia Insurance Limited holds relevant to my our insurance or any claim made under this insurance I WE authorise Allianz Australia Insurance 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 Ob sicconviswediiauennvenneennmieninontannentsvouns MDS day OF eronneen VOOM orrena Signature of All Insured S isse irera eienn teada iaa EE a aSa NiE etolgan ie E E AE A E E E EEA 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 at
10. s occurred 0 seeeee eee EE E E bapa sn E lance vod wabedun ovate c Do you have all the sets of keys for your vehicle Yes No _ If Yes please provide serial numbers Ignition Key Serial NO cece ceeceeceeceeeceececeeceseeseceseeseeevaeentseeeeaeeaaee Fite Cap Serial INU M ineine sosiaa e areia ei irei aa If No where are the keys If unknown state unknown ee E cs E E E E Sava eles supa aia ha we d Did anyone else have a set of keys to your vehicle Yes No If Yes please give details below Title O Mr O Mrs Miss Ms WO the AA EE EEE T reece Date of Birth Day Month _Year_ First ING Giesser epo ra a a E NE Last NaM E cassesa elec ceux enasecacecasctagreceneesnss cc navoseesntucaancatdencababude tea aceakcasetceacnassanseamee ieeceaae a heminavexe PGT OSS ioeina pea aiaei wanstiss Sapvvs Soon E R Home PAGING sccesiivcccniaesncensenevenensenesosuiny Work PRONG s nesssvestovinsonnivnensavtacs nnnccncvanwesss Ai ssaccas E tare scat Isvease pty Seen cademnlpu A nexe talbaaiaitiaeltioad DICDUG veitiscantrinecaectisscomsianncenniset EAn aa aai e Did anyone else regularly use the vehicle but not have keys Yes No If Yes please give details below Title OM O Mrs Miss Ms Other Date of Birth _Day_ _Month 1_Near First Name Last Name Address f Was the vehicle fitted with an alarm immobiliser Yes No g If Yes to question f what make and model no is the alarm immobil
11. tention 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 Australia Limited ABN 15 000 122 850 Incorporated in Australia trading as Allianz New Zealand of Level 1 152 Fanshawe Street Auckland 1010 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

Classic Stolen or Burnt Vehicle Claim Form

Contents

Download Pdf Manuals

Related Search

Related Contents