House and Contents Claim Form - TFIB

  • House and Contents 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.

  • Contact Details

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

  • Claim Details

    Tell us what happened
  • When did this happen?*
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  • Did this incident occur at {address}?*
  • Were there any witnesses?*
  • Was the loss caused by a person other than yourself?*
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  • Was the damage caused by gaining entry?*

  • Policy Details

  • Do you have a Police Complaint Acknowledgement to attach?*
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  • Date of report*
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  • Was a list of missing items given to the Police?*

  • 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?*
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  • Is any of the lost or damaged property subject to any financial or hire purchase agreement?*
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  • Who occupies the property?*
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  • 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 policy declined, or had special terms imposed?*

  • Details of Claimed Items

  • Do you have a Schedule of Loss to attach?*
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    • 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

    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*
  • Position*
  • Date
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  • Should be Empty: