Motor Vehicle Stolen or Burnt Claim Form
Contents
1. ON Soe Complaint Ref NO ceeeeeeeeeeieeeeeeeiees Name of Attending Officer 0 0 0 0 eeeee 1 What was the vehicle mainly used for Private O Business 0 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 ee eeseeeeseeeeeeneeeeeeeeeeeeeeeeteneeeeeeeeteeneeeseneeeseaeeetsneeesnaeeessneeersaaes 3 Please give a brief description of the condition of each of these eg good average for age poor etc ENGINE eisrean PaintwOrk arrea ta ane anaa Gearbox EEEE E EAT SEALS 28 a esas Rah a E TRANSMISSION 2 2 325 svacets leeneeeattsisassasesecteeaeses SUSPENSION season aes eetee ae caetsesasucnaetseaceaniedesenpdarens cate Stering e rea e a A Body Areas a a e a aa a aa aaia aaae 1 Tyres Please give details for each tyre Date Purchased New or Used Approximate Km Travelled Front g a a a N a E a E a E Rear o yi A Aa E ea E E a 2 What type of wheels did the vehicle have Manufacturer s Standard O Mag Wheels O Other O If Mag Wheels or Other please give details 1 Were there any other accessories fitted to your vehicle at the time of the loss Yes O No O K VEHICLE ACCESSORIE ites please give detalls scx iste test Maat Aid ce eee ee Ae ed led S L KEYS 1 Do you have the keys for your vehicle Yes O No O __ if Yes please give the serial numbers below INON isinisisi Fuel Gapi unera ien na lt No where are th2. Protecta Stolen or Burnt Vehicle Claim Form Allianz Qi 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 Email motorteam protecta co nz POLICY NUMBER cccssssssseseeceeceeeeensnsennsecceeeeeeeeeeeseneeas NEUNED 1 Name of Insured ooo eccecescescsscsscsecssesssecaessesascsussessessssessssssssessessassassesaassesassaesecsacsassecsecsesaascaecaseaeescaecaecaecaeeaeeneeees 2 IPOStal L AGGESS E E A E E E E A N E 3 Contact Phone No HOME c ccesceeseseeeeeseeeeseeeeessneeesenees Contact Phone No Work cccescecessseeessteeeeeees 4 Alternative CONTAC ccceecceeeeeeeeeeeeeeeeeene
3. ach month 0000 each petrol fill 22 6 Did your vehicle run well Yes O No O If No please give details of any problems eee O OTHER Is there any other information which would help us with your claim Yes O No O DETAILS lt Yes please give details reacia a a a a a a iae 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 Owners Manual O Other O please give details eceeceeeceeeceeeneeeeeeeeaeeeaeeceeeeeaeeseaeeeaeeseeeeeaeesseeeeeeseaeeaes 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 A a E EE E eee E E E E full name EE E T AE Motion Retin A E E E A E E A EES address 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 IMWE authorise the disclosure to Allianz Australia In
4. aeseaeeeaeeseaeesaaeeeaeessaeesaeeeaeeseseesaaeseaeeteaeesaeeeaees 5 Who did you buy it om niesienia eee i a ei ie ee eee eee 6 How much did you pay for it How much was your deposit eeeeereeees 1 When did you last see the vehicle Day Date ficients MME ta AMO PMO 2 Where did it happen street and town eeeeeceeeceeeeeeeeeeeeeeeeeeeeeeeeseeseaeesaeeseaeeseaeeaeeseeeseaeeeaeeseaeesieeeeeeseaeesaeerses 3 Where was the vehicle parked garage carport driveway parking area roadside car park other 4 What purpose was the vehicle being used immediately before the lOSS ceeeeeeeeeeeeeeeeeeeeeteeeeeeeeteeeeeeeteeeeeaes 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 Has 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 by wick iii el Alln at Station Name sc enuegnieiiias eae he
5. ation is Allianz Australia Insurance 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 You have rights of access to and correction of this information subject to the provisions of the Privacy Act 1993
6. eeeeeeeeneeeeeeeeeeaes emaldan aeee aae eet 1 What is Date of Birth of the rider or last person to use the vehicle seese Female O Male O OF RIDER 2 Was this the person shown under Part A Yes O No0 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 Full Name cincinanu e a E a E NE cevecceededent slave dita TES nRa aa Eia TOUSE 4 Postal Address innn Ea E E a E e EE EEEE RNE VEHICLE 5 Best contact Phone NO 0 ccecesceeeeseeeeeeeeeeseeeeeeseeeeesneeeess Best time to contact n neeeeeeeeeeeeeeenneeeeeeneeeereeeee 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 C RIDER S 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 D RIDER S LICENCE E INSURED VEHICLE 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 O No O 2 Has the rider ever been refused vehicle insurance or had a policy cancelled or not renewed Yes O No O IF ANY ANSWER IS YES PLEASE ATTACH FULL DETAILS ON A SEPARATE PIECE OF PAPER Lice
7. ey ternos near eeren re cies a d a eaea aa aad ies tad otek deca E iE ni E 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 M RECOVERY 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 O No O if Yes details N Pee Date SERVICE 1 Who did the last service on the Vehicle 0 eeeccceeeeeeeeeeeeeeeeeeeeeeeceeeeeeseenaeeeeees ate Pit Me Sikhs HISTORY 2 Where was your vehicle Usually serviced ceccccccecceeeceseeeeeeseceeceaecececaecenecaeeaaecaeeaecaceeaecaeseaesaeeaeseeeeaeeeeeeaeeaess 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 ccceeeesseseserereeee When does the WoF expire cee 5 Did you vehicle need extra oil between services Yes O No O If Yes how much every 1 000 KM cceeeeeee oe e
8. nce Number ccesceeceseeeeeeseeeeeeeeeeeenenes Learner O Restricted O Full O Date Issued Classes Any Special Licence Conditions T Makei i iisisie atin had seina Qs COOU cincccs seks cabecenticnducd e aoaaa EEE E 2 Modeli ironien 10 Engine Rating icenian ie ee ees Se NOON ron e E 11 Engine Type Carburettor O Fuel Injected O Turbo Charged O 4 Mileage srian iinn 12 Transmission Manual O Automatic O 5 Registration Number ecce 13 Japanese 2 Hand Import Yes O No O 6 Vin Number seision 14 Has the vehicle been modified from the manufacturer s Te CHASSIS enana standard design or specification Yes O No O 8 Engine Number ee eeeeeeeeneeerereeees If Yes to question 14 please give details 2 2 0 ce cee ceceeseneeeeeeeeeeeneeeeeaeeeseaeeeeneneeeseaeeessaeeeeaeeeseaneeeeeeeenieeeessaeeereneee te Version 01012013 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 or 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 siirinsesi otti e Sena eed idles iene deine 4 When did you buy the Vehicle oo cece ccceeseeeeseeeeeceeseeeeaeeseeeeseeeeaeees
9. surance 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 e IME 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 e IME 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 at 0c cee eeeeeeeee nets eee eee eee eeeeeaes THIS pensii Cay Of ose oiviieeebngeiee cast yea ronnan Signature of All INSULEdS i322 tnrercae ein E iene ie a E BCl1ORC IMG EAT EE EETA A AA AEEA ue na A EN E AAAA 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 Pursuan he PRIVACY ACT 1 he following is brough r ntion 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 inform
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