All questions on this form must be clearly and fully answered, otherwise processing of this claim may be delayed until the required information is supplied.
If any question does not apply to the circumstances of your claim, it must be marked “not applicable”.
The insurers do not admit liability by the issue of this form.
Maximum number of witnesses reached.
I/we declare that to the best of my/our knowledge and belief these particulars are complete and accurate. I/we have not withheld any information or details of previous claims or any other material fact likely to affect acceptance of this claim.
a. Agree to give any further information required;
b. Understand you require this personal information, which will be retained by Nautical / Vero NZ Limited before you can evaluate my/our claim;
c. Authorise the disclosure of this personal information regarding the claim to other parties;
d. Authorise the obtaining by Nautical / Vero NZ Limited from any other party personal information about me/us that is in your view relevant to this claim;
e. Authorise the obtaining by Nautical / Vero NZ Limited from any other party personal information about me/us that is in your view relevant to this claim;
f. Authorise Vero NZ Limited to place details of this claim on the database of "ICR Ltd, PO Box 474, Wellington", where it will be retained and available to other insurance companies to inspect;
g. Understand that I am/we are entitled to have certain rights of access to and correction of the personal information held by Vero and ICR Ltd.
HoursMonday – Friday8:30 am – 5 pm
Phone0508 628 8425+64 3 384 1694
Address62 Riccarton RoadRiccartonChristchurch 8011
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