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General Claim Form
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Indicates required field
Name
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First
Last
Address
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Line 1
Line 2
City
State
Zip Code
Country
Home phone Number
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Mobile phone number
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Work phone number
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Email
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Bank Account Details
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Date of loss
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Where did the loss occur?
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What happened?
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If the loss was caused by another person, please give name, address and contact details
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Please give details of any claims you have made in the last 5 years
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Are you the sole owner of the property
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Yes
No
Was an alarm fitted?
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Yes
No
Is there any other insurance relating to this loss?
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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
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NZ Police file number
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Property Schedule
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