General Claim Form

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Home phone Number *

Mobile phone number *

Work phone number *

Email *

Bank Account Details *

Date of loss *

Where did the loss occur? *

What happened? *

If the loss was caused by another person, please give name, address and contact details *

Please give details of any claims you have made in the last 5 years *

Are you the sole owner of the property *

Yes No

Was an alarm fitted? *

Yes No

Is there any other insurance relating to this loss? *

For Theft / Burglary

You must immediately inform the police if property has been lost or if you suspect burglary, theft, arson, malicious damage or any other criminal act that has caused the damage or loss. Please attach a copy of the Police acknowledgement form or note file number below

Date Reported *

NZ Police file number *

Property Schedule

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