Assurant Insurance car Claim form

We are sorry to hear that you have had an accident and we hope you are okay. Please complate the form bellow and a claims administrator will reach out soon.

"*" indicates required fields

INSURED DETAILS

Policy NumberPolicy Holders Name*Date of Birth*Preferred Contact Number*Email address*

Address*

Street Address

Address Line 2

City

Post Code

DRIVER DETAILS

Was The Insured The Driver*Drivers Full Name*Drivers Date of Birth*Drivers Phone Number*Licence Number*Version Number*Licenece Held*

Insured Vehicale

Make and Model*Year*Rego*

Particulats of Accident

Date*

MM slash DD slash YYYY

Time*

Hours
:

Minutes

AM/PM

Bref Description Of Accident / Theft

Current Location of Vehicle*

Street Address

Address Line 2

City

Post Code

Is the vehicle moveable*

Third Party details

NameInsurance DetailsRegoPhoneEmailAddress

Decloartion*

I Have Read And Accept The DeclorationPursuant to the PRIVACY ACT 2020 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 the insurer detailed in your Insurance Policy.
4. The information is being collected and held by Protecta Insurance New Zealand Limited of 110 Symonds Street, Grafton, 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 2020.
I/We declare that the information given in this claim is correct.
I/We agree that, should there be any dispute over any payment of this claim, Protecta and/or the insurer shall be entitled to submit the dispute to arbitration.
I/We authorise and request the New Zealand Police to release to Protecta and/or the insurer copies of any or all documents held by the New Zealand Police
relating to the incident giving rise to this claim. If necessary this authority should be treated as a formal request pursuant to the Official Information Act 1982.
I/We authorise the disclosure of personal information held by the Ministry of Justice, NZ Transport Agency and any other party regarding this claim.
I/We authorise Protecta and/or the insurer to:
– check details against the Insurance Claims Register and to place information on the Insurance Claims Register which other insurers can access.
– disclose personal information to other parties, members of the insurance industry and/or parties who have a financial interest in the subject matter of this insurance