Pursuant to the Privacy Act 1993 the following is brought to your attention. This claim form collects personal information about your claim; The information is collected to evaluate your claim; The intended recipient of the information is: The Insurer named below (Hererinafter called “the company”) and BrokerWeb Risk Servies Ltd (Hereinafter called BWRS) and is being held by them at their offices.	The collection of this information is required pursuant to the terms of your insurance policy; The failure to provide this information may result in your claim being declined; You have rights of access to, and correction of, this information subject to the provisions of the Privacy Act 1993.

Policy Number:	Click here to enter text.	Insurance Company:	Click here to enter text.

POLICY HOLDER DETAILS
Full name: (Company name if applicable)	Click here to enter text.
Address:	Click here to enter text.
Contact Phone No: (home)	Click here to enter text.	(Business)	Click here to enter text.
Email:	Click here to enter text.
Bank account details for direct credit payment:	Click here to enter text.
CIRCUMSTANCES OF LOSS
When did the loss occur?	Date:	Click here to enter a date.
Day:	Click here to enter text.	Time:	Click here to enter text.	☐AM ☐PM
Where did the loss occur?	Click here to enter text.
Please explain what happened:	Click here to enter text.
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If loss caused by another person, please provide:	Name:	Click here to enter text.
Address:	Click here to enter text.
DETAILS OF PROPERTY LOSS OR DAMAGE
Are you the sole owner of the property concerned?	☐Yes / ☐No
If no, please provide details:	Click here to enter text.
If burglary, loss or theft claim, to which Police Station was it report?	Click here to enter text.
Date reported:	Click here to enter text.
Police acknowledgement form attached:	☐Yes / ☐No
If no, please provide incident reference:	Click here to enter text.
If burglary, state means of entry to the premises:	Click here to enter text.
PROPERTY SCHEDULE
Please attach proof of ownership (i.e. purchase receipts and quotes for replacement)
Item or property lost or damaged:	Purchase date & price:	Present cost of replacement:	Amount claimed:
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DECLARATION: Note failure to provide full and truthful information could result in the claim being declined.

I/We agree to BWRS/The Company disclosing my/our personal information regarding this claim to:

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

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

I/We understand that I am/we are entitled to have certain rights of access to and correction of the personal information held by BWRS/The Company & ICR Ltd

I/We agree to BWRS/The Company obtaining personal information about me/us that is, in BWRS’s view, relevant to this claim.

From any other party including other members of the Insurance Industry and from ICR Ltd which holds details of claims made by me/us under policies with other insurers. All the information and answers (whether written or oral) given to BWRS/The Company in connection with this claim are correct and that no information relevant to the claim has been omitted. I/We authorize BWRS/The Company to act on my/our behalf.

Policyholder’s Signature:	Date:	Click here to enter a date.
Company: (please state capacity)	Click here to enter text.