Claims

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.

Policy Details

Client Number

Policy Number

Policy Holder First Name *Note: This could be the name of a Company or Trust

Policy Holder Last Name *

First Name of person completing this form *

Last Name of person completing this form *

Claim Excess

NZD

Email Address *

Phone *

Address *

City *

Postcode *

Country *

Do you prefer correspondence to be via email or mail? *EmailMail

Vessel Details

Vessel Name

Type *

Incident Details

Time of Incident *

Date *

Location of Incident *

What happened? *

What speed (km/h) was the vessel going?

Weather ConditionsGoodFairVery Poor

Water ConditionsCalmModerateRough

TideLowMidHigh

Wind Speed (Knots)Under 1516-2930-40Over 40

Helm person at the time of the incident

Relationship of helm person to the insured

Helm person (or driver towing the vehicle) had consumed any intoxicating liquor or taken any drug within 12 hours of the incident *YesNoNot applicable

Name of Liquor/Drug

Quantity

Period of consumption

Full details of the damage to the insured vessel *

Assessment Details

Address where vessel can be inspected

Street Address

City

ZIP / Postal Code

Country

Estimate for cost of repairs obtainedYesNo

Attach quote (if available)

Max. file size: 5 MB. Max # of files: 5

Estimate amount

NZD

Estimate made by

Action (if any) taken to minimise loss/damage or liability *

Ownership Details

You own all the damaged/lost property *YesNo

Owner First Name

Owner Last Name

Street Address

City

State/Province

ZIP / Postal Code

Country

Do you have any other insurance that covers this claim *YesNo

Sum Insured ($)

NZD

Company

Branch

Theft Details

If burglary / theft / loss / malicious damage occurred, the police have been notified *YesNoNot applicable

Station reported to

Date

Other Parties

No liability should be admitted by you, or any offer made to compensate for damage.
All communications received should be forwarded to us immediately.

Do you consider the incident to be the fault of any person other than yourself *YesNo

Details regarding the other person's culpability for the incident

The other person admitted liabilityYesNo

Details of the admission of liability

Please provide details of the owner of the other vessel or property

First Name

Last Name

Street Address

City

State/Province

ZIP / Postal Code

Country

Phone

Insurance Company

Damage to other property (if applicable)

Names and addresses of all witnesses (include all passengers in your vehicle)

Sketch plan and photos if available

Max. file size: 5 MB. Max # of files: 5

Declaration

Please read & agree.

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.

I/we:

Agree to give any further information required;
Understand you require this personal information, which will be retained by Nautical / Vero NZ Limited before you can evaluate my/our claim;
Authorise the disclosure of this personal information regarding the claim to other parties;
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;
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;
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;
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.

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Please provide details of the owner of the other vessel or property