Motor Claims Form

1 Contact Details

2 YOUR DRIVER DETAILS

3 Incident Details

4 Third Party

YOUR DRIVER DETAILS
Title*
- Mr
- Mrs
- Ms
- Miss
First Name*
Middle Name(s)
Surname*
Date of Birth*
Date Format: DD slash MM slash YYYY
Business Phone
Mobile Phone
Driver's License No.*
License Version No.*
Expiry Date*
Date Format: DD slash MM slash YYYY

INCIDENT DETAILS
Date of Incident*
Date Format: DD slash MM slash YYYY
Time of Incident*
Vehicle Make*
Vehicle Model*
Vehicle Registration No*
(If vehicle does not have a registration number, please provide description).
Please advise what happened and details of the damage.*
Incident location:*
Please provide any photos you may have taken of the damage. (Max 20 photos)

These file types are recommended: .jpg, .jpeg, .png, .pdf
Accepted file types: jpg, jpeg, png, pdf.
Accepted file types: jpg, jpeg, png, pdf.
Accepted file types: jpg, jpeg, png, pdf.
Accepted file types: jpg, jpeg, png, pdf.
Accepted file types: jpg, jpeg, png, pdf.
Accepted file types: jpg, jpeg, png, pdf.
Accepted file types: jpg, jpeg, png, pdf.
Accepted file types: jpg, jpeg, png, pdf.
Accepted file types: jpg, jpeg, png, pdf.
Accepted file types: jpg, jpeg, png, pdf.
Accepted file types: jpg, jpeg, png, pdf.
Accepted file types: jpg, jpeg, png, pdf.
Accepted file types: jpg, jpeg, png, pdf.
Accepted file types: jpg, jpeg, png, pdf.
Accepted file types: jpg, jpeg, png, pdf.
Accepted file types: jpg, jpeg, png, pdf.
Accepted file types: jpg, jpeg, png, pdf.
Accepted file types: jpg, jpeg, png, pdf.
Accepted file types: jpg, jpeg, png, pdf.
Accepted file types: jpg, jpeg, png, pdf.
Do you have a preferred repairer?
Were the police notified?*
- Yes
- No
Was the incident your fault?*
- Yes
- No
Did the other party admit liability?*
- Yes
- No

THIRD PARTY DETAILS IF APPLICABLE
Only complete this section if there was another party involved
Title
- Mr
- Mrs
- Ms
- Miss
First Name
Middle Name(s)
Surname
Business Phone
Mobile Phone
Email Address
Third Party Vehicle Registration
Third Party Insurer
Third Party Property Damage
PLEASE NOTE
- Cactus Insurance Group does not admit liability by the issue of this form.
- Any occurrence or claim must be notified to Cactus Insurance Group immediately.
- You must not incur any expenses without the written consent of Cactus Insurance Group.
- You must not make any admission of liability, offer of settlement, promise or payment without the written consent of Cactus Insurance Group.
- Failure to provide full and correct information could result in your claim not being accepted by Cactus Insurance Group.
- Please retain damaged goods in case inspection is required.
- Please attach estimates in support of repairs as appropriate along with any other relevant documentation.
CLAIM FORM DECLARATION
I/We declare that to the best of my/our knowledge the information provided in this form is complete and accurate.

I/We:
1. Agree to provide any further information that may be required;
2. Understand that you require this personal information in connection with this claim and that it will be retained at Level 2, 1 College Hill, Freemans Bay, Auckland 1011;
3. Authorise the disclosure of this personal information associated with this claim to other parties;
4. Authorise you to obtain from any other party personal information about me/us that you may consider to be relevant to this claim;
5. Authorise you to add details of this claim to the database of the Insurance Claims Register Ltd (ICR Ltd) where it will be retained and available for other Insurers to access;
6. Authorise you to obtain from Insurance Claims Register Ltd (ICR Ltd) details of claims made by me/us;
7. Understand that I/We have certain rights of access to and correction of personal information held by you and Insurance Claims Register Ltd (ICR Ltd);
8. Understand that failure to provide all personal information requested by you in relation to this claim may result in the claim being delayed or denied.
*
- I have read and accept these conditions

CONTACT DETAILS

Policyholder Name

OR

Contact details of the person completing this claim

YOUR DRIVER DETAILS

INCIDENT DETAILS

THIRD PARTY DETAILS IF APPLICABLE

Only complete this section if there was another party involved

PLEASE NOTE

CLAIM FORM DECLARATION