Motor Claim Form - TFIB

  • Motor 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.

  • Insured Vehicle Details

  • At the time of the accident was the vehicle being used for business or carrying any goods?*
  • Was your vehicle damaged?*
  • Do you know the repairer you are going to use?
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Insured / Company name cannot contain “,*,:,,?,/,|, Please check your response

  • Details of Driver or Person in Charge

  • Was it the insured driving when the accident occured?*
  • Date of Birth*
     - -
  •  -
  • Type of Licence*
  • Are you the Policy Holder?*
  • Was the vehicle being driven with the owners consent?

  • In the past five years has the driver;

  • Had any losses / incidents involving damage or theft of a vehicle? (excluding glass)*
  • Been disqualified from driving or had license suspended or cancelled?*
  • Been convicted of any offence other than parking or speeding?*
  • Had any insurance refused, cancelled, special terms imposed or had a claim declined?*
  • Rows

  • Incident Details

  • Date of Incident*
     - -
  • Rows
  • If any of the items were present were they in your favour?*
  • Was the road wet at the time of the accident?*
  • Was the accident your fault?*

  • Third-party damage

  • Were any other vehicles or property involved in the accident? *
  •  -
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Authorities and Witnesses

  • Was the accident reported to the Police?*
  • Was any intoxicating liquor and/or drugs (prescribed or otherwise) consumed by the driver in the 12 hours prior to the accident?*
  • Was a breathalyser, blood test or any other test requested?*
  • Were there any other passengers in your vehicle or any other witnesses?*
  • Rows

  • 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 this declaration form and have the authority to do so.
  • Position*
  • Date*
     - -
  • Should be Empty: