This form collects personal information about you so we can consider your claim and update your insurances. It will be held by Exclusive Insurance Services and the underwriter who handles your claim. You may request access to, and correction of, this information subject to the provisions of the Privacy Act 1993. The collection of this information by Exclusive Insurance Services is required under the terms of your insurance policy. Failure to provide this information may result in your claim being declined.
I declare that to the best of my knowledge the details given in this claim form are true.
I undertake to render all possible assistance in connection with this claim.
I agree that Exclusive Isurance Services and the insurance company (&/or their agent) with whom I am insured may give to or obtain from appropriate individuals or organisations information relevant to this claim.
I agree that the insurance company with whom I am insured may give to or obtain from ICR details or information relevant to this claim. (The Insurance Claims Register Ltd (ICR) holds details of claims under policies issued by participating insurers. Participating insurers can check details of your claims history on the ICR).
Established in 2006, Exclusive Insurance Services have worked hard to build a trusted and reliable reputation offering innovative and affordable risk management and insurance solutions to our extensive and rapidly growing client base.
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Level 2, 63 Albert Street,
Auckland 1010 New Zealand
P: +64 9 307 1295
M: +64 21 493 816
F: +64 9 307 6795