Theft of vehicle or
accessories claim form
0800 252 461 | claims.team@crombielockwood.co.nz
Return to: Crombie Lockwood Claims Team, Private Bag 11007, Palmerston North 4442
claims.team@crombielockwood.co.nz
This form collects personal information about you so we can consider your claim and update your insurances. It will be held by Crombie Lockwood (NZ) Limited and
the underwriter who receives 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 Crombie Lockwood (NZ) Limited is required under the terms of your insurance policy. Failure to provide this information may result
in your claim being declined.
PERSONAL DETAILS
Contact person:
If Trust, Company or Body Corporate
Email:
Contact’s phone number:
Address:
Policy reference client number:
Preferred method of contact:
Crombie Lockwood Branch you are insured through:
LOSS DETAILS
1. Particulars of Vehicle:
Year:
Make:
Wof Exp:
Model:
Reg. No:
Reg. Exp:
Finance details:
2. When stolen:
Time:
am / pm
Date:
3. Has the vehicle / accessories been recovered:
⬜
Yes
⬜
No
Where:
By whom:
4. Is the vehicle mobile? If ‘no’ state where it is:
⬜
Yes
⬜
No
Where:
5. What damage is there to the vehicle:
See question 27 for accessories
6. Has the vehicle or its engine been modified
since manufacture? If ‘yes’ give details:
⬜
Yes
⬜
No
7. Details of existing defects or damage:
Engine:
Interior:
Body work:
Tyres:
8. Who usually services your vehicle:
Name:
Phone:
Date last serviced:
9. Who parked the vehicle prior to the theft:
Name:
Date of birth
Address:
Phone:
Insured name: Date of birth:
<Select>
<Select>
PM
Return to: Crombie Lockwood Claims Team, Private Bag 11007, Palmerston North 4442
claims.team@crombielockwood.co.nz
10. Where was the vehicle parked:
Address:
⬜
Garage /
Carport
⬜
Parking
area
⬜
Driveway
⬜
Roadside
⬜
Other:
11. Why was the vehicle left there:
12. When did you last see the vehicle:
Time:
am / pm
Date:
13. When did you know the theft had occurred:
Time:
am / pm
Date:
14. Was the vehicle fully locked and secure?
If ‘no’ state give details:
⬜
Yes
⬜
No
15. How many sets of keys were there for the vehicle:
⬜
1
⬜
2
⬜
3
⬜
4
⬜
5 or more, please give exact number:
16. Where were each set of keys when the theft occurred:
17. Was the loss reported to the Police:
⬜
Yes
⬜
No
Police station:
When reported:
By whom:
Police file no:
If you answer "Yes" for any questions (18 to 26) please give full details
If yes - details:
18. Have you any idea who the offender was?
⬜
Yes
⬜
No
19. Is there any other insurance on the vehicle or
accessories?
⬜
Yes
⬜
No
20. Are you behind in your Finance / Hire purchase
payments?
⬜
Yes
⬜
No
21. Have you any indication how entry was gained?
⬜
Yes
⬜
No
22. Since owning this vehicle have you had it insured
with any other insurance company?
⬜
Yes
⬜
No
23. Have you been trying to sell the vehicle or
accessories?
⬜
Yes
⬜
No
24. Have you had any motor vehicle accidents or
losses in the last 5 years?
⬜
Yes
⬜
No
25. Have you had any traffic or criminal
convictions in the last 5 years?
⬜
Yes
⬜
No
26. Have you any other information relevant to
this claim
⬜
Yes
⬜
No
STOLEN VEHICLE ACCESSORIES
27. Please list details of the items below:
Item
Make & Model
Serial No.
Purchased from:
Age:
Present purchase price
Please attach receipts, guarantees or other documents which support ownership or value, as well as any quotation that may support your claim.
PM
PM
Return to: Crombie Lockwood Claims Team, Private Bag 11007, Palmerston North 4442
claims.team@crombielockwood.co.nz
FURTHER INFORMATION OR COMMENTS
DECLARATION
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 Crombie Lockwood (NZ) Limited and the insurance company (and/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 of 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 at ICR.)
Note: Failure to provide correct and complete information could result in your claim not being accepted by the insurance
company.
⬜
I have read and I understand the above Declaration
⬜
I have read and I understand the above Declaration
Signature of Insured:
(person completing this form)
Signature of Driver:
Date:
Date:
DIRECT CREDIT DETAILS
Bank Branch Number
Account Number
Suffix
⬜⬜⬜⬜⬜⬜
⬜⬜⬜⬜⬜⬜⬜
⬜⬜⬜
Account Name:
CROMBIE LOCKWOOD CLAIMS CONTACT
Claim Handler:
Claims Team
Phone Number:
0800 252 461
Email:
claims.team@crombielockwood.co.nz
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Claims Team
0800 252 461
