General Claims Online Form

Complete the form below to submit your General Claim. If you would prefer, you can download a copy of the General Claim form instead. This form can be filled in on a computer or printed and filled in by hand. Please email any forms completed this way to team@tsibrokers.co.nz to complete the submission.

General Claim Form

Download

Part A: Policy Holder
Full name of insured*
Postal address
Phone
Email*
Bank account no. for direct credit payment
Part B: Circumstances of Loss. Please Complete in all Cases
Date*
Date Format: MM slash DD slash YYYY
Time

: HH

MM
Where did the loss occur?*
Please explain what happened*
Is there any other insurance with any Company related to this loss?
If so, give particulars
If loss caused by another person please give name and address
Have you, within the past 5 years, made a claim against any Insurance Company?
If so, please provide details including Company name
Are you the sole owner of the property concerned?
- Yes
- No
If "No" supply details of other interest and party concerned
If burglary, loss or theft claim
To which Police station was it reported?
Date Reported
Date Format: MM slash DD slash YYYY
Acknowledgement from attached,
If burglary, state means of entry to premises
Part C: Property Schedule
Lost or damaged property (state each article/item separately. Use the plus button to add additional rows)
Description of property lost or damaged Date Purchased & Price Present Cost of Replacement Depreciation for Age and Condition Value of Salvage (if any) Amount claimed
Attach additional lost or damaged property details
Part D: Public Liability
Name and address of owner of property damaged
Phone No.
Insurance Co. (If known)
DECLARATION: NOTE* Failure to provide full and truthful information could result in the Claim being declined.
1. I/We agree to The Company disclosing my/our personal information regarding this claim to:

(a) Other parties including other members of the Insurance Industry and the database of the Insurance Claims Register (ICR Ltd) P.O Box 474, Wellington, where it will be retained and made available to other insurance companies to inspect

(b) Parties who have a financial interest in the subject matter of the policy and parties repairing or replacing the subject matter of the claim.

(c) I/We understand that I am/We are entitled to have certain rights of access to and correction of the personal information held by The Company and ICR Ltd.
2. I/We agree to The Company obtaining personal information about me/us that is, in The Company's view, relevant to this claim.

(a) From any other party including other members of the Insurance Industry and from Insurance Claims Register (ICR Ltd) which holds details of claims made by me/us under policies with other insurers.

3. I hereby declare that the answer given above are in every respect correct and I make a solemn declaration conscientiously believing the same to be true and by virtue of the Oaths and Declarations Act 1957.
If company, state capacity
Insured Signature*
Date
Date Format: MM slash DD slash YYYY
CAPTCHA

Description of property lost or damaged	Date Purchased & Price	Present Cost of Replacement	Depreciation for Age and Condition	Value of Salvage (if any)	Amount claimed

Part A: Policy Holder

Part B: Circumstances of Loss. Please Complete in all Cases

Part C: Property Schedule

Part D: Public Liability

DECLARATION: NOTE* Failure to provide full and truthful information could result in the Claim being declined.