Motor Vehicle Accident Claim Form (Page 4 of 4) in pdf

Motor Vehicle Accident Claim Form Page 4

8. Sketch Plan of Accident

1. Please make a rough plan of road showing distance and positions of all vehicles and persons concerned showing by

arrows the direction in which they were travelling.

2. Your vehicle to be marked (A) and the other parties (B), (C) and so on, with point of compass shown.

9. Declaration – Signature

I declare that:

1. All of the statements and information in this claim form are correct;

2. I have told Allianz everything which may be relevant to this claim;

3. I understand that:

(a) I am required to co-operate with Allianz and provide this information and if I do not, Allianz may decline my claim;

(b) I have certain rights of access to and correction of the personal information provided by me on this claim form or in

support of this claim. But if I do provide any incorrect information, Allianz may be entitled to decline my claim whether

or not it is later corrected;

4. I authorise Allianz to obtain personal information about me from any other party and to release that information to other

parties if requested;

5. I authorise Allianz to obtain copies of any documents or information relating to this claim from the New Zealand Police.

Dated at

this

day of

Driver’s Signature

Insured’s Signature

10. Repair Authorisation

I hereby authorise the

Garage to repair on my behalf the

car/truck Engine No.

Registration No.

damaged on

Date

Insured’s Signature

Allianz New Zealand Limited. Registered Office: 45 Queen Street Auckland New Zealand

MVNZ_0001 (9/01)

Motor Vehicle Accident Claim Form Page 4