THE INSURED'S INFORMATION
Insured's/Owner's First Name *
Insured's Family Name/Surname *
Date of Birth *
Taxi company name or group that you drive for *
Region/Area  
Policy Number  
Email Address  
Telephone Day
Telephone Night
Mobile *
Postal Address *
Interested Party (Bank, Finance Company etc.)
Postal Address
THE INSURED TAXI
Year *
Make/Model *
Registration No. *
V.I.N Number *
cc
Is the Certificate of Fitness Current?
If NO, why?
*
Is there any other insurance on this taxi?
If YES, with whom?
*
THE DRIVER OR PERSON IN CHARGE OF THE TAXI DETAILS
Driver's First Name *
Driver's Family Name/Surname *
Date of Birth *
Email Address  
Telephone Day  
Telephone Night  
Mobile *
New Zealand Driver Licence No. *
Card Version No. *
Date of Issue *
Expiry Date *
Type of Licence at the time of accident
*
Was the Driver

 
If other specify whom?
*
Was the taxi being driven without the owner's knowledge and consent?
If Yes, please supply details
*
Had the driver taken any medication in the 24 hours prior to the accident?
If Yes, please supply details
*
Had alcohol and/or drugs been consumed by the driver in the 24 hours prior to the accident?
If Yes, please supply details
*
Was the breathalyzer, or blood test, or other test required?
If Yes, please supply details
*
In the last five years has the driver:
a) Had any insurance cancelled or refused?
If Yes, please supply details
*
b) Had a driving licence endorsed, suspended or cancelled?
If Yes, please supply details
*
c) Commited, been charged with or convicted of any criminal or traffic offence (other than parking)?
If Yes, please supply details
*
d) Been convicted of driving while under the influence of drugs or alcohol?
If Yes, please supply details
*
e) Had any previous accidents or made a claim on a motor vehicle insurance policy?
If Yes, please supply details
*
Name of the Driver's Insurance Company  
DAMAGE TO VEHICLES INVOLVED IN ACCIDENT
INSURED TAXI
Describe the damage to the taxi (e.g. bumper and right rear panel) *
Damage to wind screen
*
Damage to other windows
*
Were Accessories damaged or stolen ?
If Yes, which items and value
*
Was a trailer being towed at the time of the accident?
If Yes, please supply details
*
Is the taxi drivable?
*
Where and when can it be inspected? *
Have you got a quote
If Yes, email or mail to our contact address
Amount of estimate for repair
*
OTHER VEHICLES INVOLVED IN ACCIDENT
Are there any other vehicles involved in accident
If Yes, complete the section below
*
Owner's Name *
Address *
Telephone *
Make/Model *
Registration No. *
Insurance Company *
Third Party Driver's Name *
Address *
Telephone *
Make/Model *
Registration No. *
ALL WRITTEN COMMUNICATIONS FROM ANY OTHER PARTY MUST BE FORWARDED IMMEDIATELY TO US
POLICE DETAILS
Did the police attend the scene?
*
If NO, have the police been notified of the loss?
*
If Yes, which police station was the loss reported to?
Date loss reported to police?
Police File/ Event Number?
Have the police recovered any property?
*
Has the loss been advertised in any newspapers?
If Yes, which paper?
*
Date Advertised?
Other actions taken to recover property
Please forward the police form to us in all cases of theft or loss.
WHAT HAPPENED
Date of the accident
Time of the accident
* 
Were there any independent witnesses (not passengers in your taxi)? If Yes, give details
*
Witness 1 Name
Witness 1 Telephone
Witness 1 Address
Witness 2 Name
Witness 2 Telephone
Witness 2 Address
Were there any passengers aged 15 years or older in your vehicle at the time of the accident?
If Yes, give details
*
Passenger 1 Name
Passenger 1 Telephone
Passenger 1 Address
Passenger 2 Name
Passenger 2 Telephone
Passenger 2 Address
Exact location of the accident *
Where had you been and where were you going? *
What purpose was the vehicle being used for at the time of the accident?
If business, give details
*
What were weather conditions at the time of the accident?
*
Give full and precise details as to how the accident occured *
What speed were you travelling prior to the accident? *
The other vehicle speed?
Whom do you consider to be at fault? (give reasons)
Did either party admit liability?
If Yes, give details
*
Has anyone been charged with any offence in connection with the accident?
If Yes, give details (who/type of charge)
*
Did accident cause damage to property (i.e fences, walls, posts etc.) of others? If Yes, provide details:
Name
Address
Telephone Number



*
Please give details of anything else you feel may be relevant to this accident
Is loss of use required?
*
DECLARATION

Where any declaration is answered NO, further details will need to be provided below in the box headed 'Exceptions to this Declaration'.

I/We declare that: All the statements in this claim form and any additional schedules are correct.

The taxi and/or accessories are correctly described in this form and were lost, stolen or damaged under the circumstances described in the form above.

I/We have told THE INSURANCE GROUP and CLUB AUTO everything relevant to this claim


I/We understand that:

Wilful or reckless exaggeration or inflation of the amount claimed will forfeit the claim and may result in prosecution.
The personal Information provided in this claim form is being collected by THE INSURANCE GROUP, CLUB AUTO and TOWER to enable them to evaluate MY/OUR CLAIM.

I/We agree that, should there be any dispute over any payment of this claim, the Insurer or its authorised agent shall be entitled to submit the dispute to arbitration.

I/We have certain rights of access to and correction of the personal information provided by me/us on this claim form or in this claim, but if I/We do provide incorrect information, CLUB AUTO or TOWER may be entitled to decline the claim whether or not it is later corrected.

If any of the property in this claim for which I/We have received payments is subsequently recovered I/We will notify THE INSURANCE GROUP, CLUB AUTO or TOWER immediately and return the property to CLUB AUTO or will refund to THE INSURANCE GROUP, CLUB AUTO or TOWER the value of the recovered items.

I/We authorise THE INSURANCE GROUP, CLUB AUTO or TOWER to obtain or release personal information about me/us from any other party.

I/We authorise THE INSURANCE GROUP, CLUB AUTO or TOWER to obtain if required a copy of the police report from the police relating to the claim I/We authorise and request the New Zealand Police to release to the Insurer or its authorised agent copies of any or all documents held by the New Zealand Police relating to the incident giving rise to this claim. If necessary this authority should be treated as a formal request pursuant to the Official Information Act, 1982.

I/We agree to the Insurer or its authorised agent releasing to other parties personal information regarding this claim.

I/We authorise the Insurer or its authorised agent to give or obtain from other insurers or other parties any information relating to any insurance.

Note: Failure to provide full and correct information could result in your claim not being accepted by the Insurer or its authorised agent.


State your position  


NOTE: To complete your claim a copy of your Driver Licence is required.

Please send by email or regular post a photo or scanned copy of your Driver Licence.

email to: claims@igroup.co.nz

or post to:
Taxi Insurance Claims
The Insurance Group
P.O.Box 92-116
Auckland 1142