Club Auto Insurance products include, Vehicle Insurance, Third Party Insurance, Motorbike Insurance

1.2 Disclosure

In the last five years have you, the driver, person in charge or anyone covered by this policy

a) Had any accidents, damage, or theft, whether a claim was made or not (regardless of fault)*

Yes

No

Details if yes*

b) Had a driver license endorsed, suspended, cancelled or disqualified?*

Yes

No

Details if yes*

c) been charged with, convicted of, or committed any driving or vehicle related offences ( excluding parking ) ?*

Yes

No

Details if yes*

d) had motor vehicle insurance declined, cancelled, refused or special terms imposed?*

Yes

No

Details if yes*

e) had any insurance claim denied?*

Yes

No

Details if yes*

f) have you been convicted of or committed any criminal offence (other than traffic or parking offences), have prosecutions or convictions pending, or been bankrupt or undergone a No Assets Procedure in the last 10 years?*(Subject to the Criminal Records (Clean Slate) Act 2004)

Yes

No

Details if yes*

2.0 Insured Vehicle Details

Year*

Reg no.*

Make.*

Model*

Sub Model*

Has the vehicle been modified in any way?

Yes

No

Please give full details how the vehicle has been modified*

Is the vehicle certified for the modifications?*

Yes

No

N/A

If no please give full details*

Is there any other insurance on the vehicle or accessories?

Yes

No

If yes please give full details

Was the WOF/COF current at the time?*

Yes

No

If no please give full details*

Was there any damage to the vehicle prior to this accident occurring (including mechanical)?

Yes

No

If yes please give full details

Are any Road User Charges up to date?*

Yes / N/A

No

If no please give full details*

Is the vehicle subject to a finance arrangement of any kind?*

Yes

No

If yes please give full details*

Does the vehicle ever get used as a work vehicle to earn income?*

Examples include:

making deliveries
transporting paying passengers
use as a work vehicle for real estate agents, tradespeople etc

Yes

No

Please provide information

what you usually use your vehicle for
what you were using for at the time of the loss

2.1 Damage to the vehicle

Is there any damage to your vehicle?

Yes

No

Describe the damage to the vehicle (eg. bumper and right rear panel)*

Is the vehicle drivable?*

Yes

No

Where is the vehicle currently located?*

Was the vehicle towed from the scene?*

Yes

No

If yes by whom

Repairer*

Repairer's Name

Repairer's Phone

You may find a repairer from our preferred repairer list HERE

Please draw where the damage has occurred on your car

3.0 Third Party Damage

Were there any other vehicles involved in accident?*

Yes

No

Vehicle 1

Driver

Street Address

Suburb

Town / City

Phone

Mobile

Email

Vehicle Owner/Company (if different from the driver)

Make/Model

Reg No.

Insurance Company

Claim Number

Details of damage to their vehicle

Was the third party known to you prior to the accident?*

Yes

No

If yes please give details

Was there another vehicle involved in accident?*

Yes

No

Vehicle 2

Driver

Street Address

Suburb

Town / City

Phone

Mobile

Email

Vehicle Owner/Company (if different from the driver)

Make/Model

Reg No.

Insurance Company

Claim Number

Details of damage to their vehicle

Was the third party known to you prior to the accident?*

Yes

No

If yes please give details

Did the accident cause any damage to property (i.e. fences, walls, posts, etc.)*

Yes

No

If Yes, please give details*

4.0 What Happened

Date of Accident*

Time of Accident*

Click on map to add up to 2 pins

Location/Address of accident*

Where had you been*

Where were you going*

What lighting conditions applied at the time of the accident?*

Dusk

Dark

Daylight

What weather conditions applied at the time of the accident?*

Fine

Rain

Overcast

Was the road Sealed or Metal?*

Sealed

Metal

What were the road conditions at the time of the accident?*

Wet

Ice/Snow

Dry

Other

Please give details*

Were there any passengers in your vehicle at the time?*

Yes

No

Passenger 1 Name

Passenger 1 Address

Passenger 1 Phone

Were there any additional passengers?*

Yes

No

Additional Passengers

Passenger 2 Name

Passenger 2 Phone

Passenger 3 Name

Passenger 3 Phone

Passenger 4 Name

Passenger 4 Phone

Give full and precise details as to how the accident occured*

What speed were you travelling prior to the accident? km/hr*

The other vehicle(s) speed? - Vechicle 1 km/hr

The other vehicle(s) speed? - Vechicle 2 km/hr

Whom do you consider to be at fault? (give reason)*

Did either party admit liability?*

Yes

No

Please give full details*

Has anyone been charged with any offence in connection with the accident?*

Yes

No

Unknown

Please give full details (who/type of charge)*

Were there any independent witnesses (not passengers of your vehicle)?*

Yes

No

Witness Details*

Were there any other witnesses (Not passengers of your vehicle)?*

Yes

No

Witness Details*

4.1 Police Details

Have the police been notified?

Yes

No

On which Date?*

Police File / Event Number

Name of Police Officer

Did the Police attend the scene?

Yes

No

5.0 Images

Please attach the following:

License photo (front and rear) for both the driver and insured person
Scene photos
Vehicle damage photos (including other party's vehicle or property)

Anything else you consider relevant e.g. other party's License

Add Image

View Summary?*

Yes

No

6.0 Declaration (Please read this carefully before submitting)

I/We declare that:

All the statements in this claim form and any additional schedules are correct.
The motor vehicle and/or accessories are correctly described in this form and were lost, stolen or damaged under the circumstances described within this form.
I/We have told Club Auto everything relevant to this claim.

I/We understand that:

Wilful or reckless exaggeration or inflation of the amount claimed will forfeit the claim and may result in prosecution.
The personal information provided in this claim form is being collected by Club Auto or TOWER to enable it to evaluate my/our claim.
I/We have certain rights of access to and correction of the personal information provided by me/us on this claim form or in support of this claim, but if I/we do provide incorrect information, Club Auto or TOWER may be entitled to decline the claim whether or not it is later corrected.
If any of the property in this claim for which I/we have received payment is subsequently recovered I/we will notify Club Auto or TOWER immediately and return the property to Club Auto or TOWER or will refund to Club Auto or TOWER the value of the recovered items.

I/We authorise Club Auto or TOWER to obtain personal information about me/us from any other party.

I/We authorise the New Zealand Police to release to Club Auto or TOWER copies of any or all documents held by the New Zealand Police relating to the incident giving rise to this claim and authorise Club Auto or TOWER to provide information about this claim and the insured to the New Zealand Police to assist with the police investigation. I/We consent to Club Auto or TOWER making a formal request pursuant to the Official Information Act, 1982 if necessary.

I accept the above declaration

I accept the above declaration with the following exceptions

I am the insured person or authorized to complete this claim form on their behalf

All the statements in this claim form and any additional schedules are correct

Full Name of person that completed this claim form*

Exceptions to the Declaration

Date*

Club Auto Insurance Claim

1.0 Policy Owners Details

Contact Details

Address Details (Postal)

1.1 Driver of your vehicle

1.2 Disclosure

In the last five years have you, the driver, person in charge or anyone covered by this policy

2.0 Insured Vehicle Details

2.1 Damage to the vehicle

3.0 Third Party Damage

Vehicle 1

Vehicle 2

4.0 What Happened

Additional Passengers

4.1 Police Details

5.0 Images

6.0 Declaration (Please read this carefully before submitting)

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