Club Auto Insurance Claim

  • Details
  • Vehicle
  • Other Parties
  • Event
  • Images
  • Declaration
  • Finished

1.0 Policy Owners Details

Contact Details

Address Details (Postal)

1.1 Driver of your vehicle

Who was driving the vehicle at the time?*

Drivers licence held*

Was the licence in full affect at the time of the accident?*

What is the driver's relationship to the vehicle owner?*

Was the vehicle being driven without the owner's knowledge and/or consent? *

Had the driver taken any medication in the 24 hours prior to the accident?*

Had alcohol and/or drugs been consumed by the driver in the 24 hours prior to the accident?*

1.2 Disclosure

In the last five years have you, the driver, person in charge or anyone covered by this policy

a) Had any accidents, damage, or theft, whether a claim was made or not (regardless of fault)*

b) Had a driver license endorsed, suspended, cancelled or disqualified?*

c) been charged with, convicted of, or committed any driving or vehicle related offences ( excluding parking ) ?*

d) had motor vehicle insurance declined, cancelled, refused or special terms imposed?*

e) had any insurance claim denied?*

f) have you been convicted of or committed any criminal offence (other than traffic or parking offences), have prosecutions or convictions pending, or been bankrupt or undergone a No Assets Procedure in the last 10 years?*(Subject to the Criminal Records (Clean Slate) Act 2004)

2.0 Insured Vehicle Details

Has the vehicle been modified in any way?

Is the vehicle certified for the modifications?*

Is there any other insurance on the vehicle or accessories?

Was the WOF/COF current at the time?*

Was there any damage to the vehicle prior to this accident occurring (including mechanical)?

Are any Road User Charges up to date?*

Is the vehicle subject to a finance arrangement of any kind?*

Does the vehicle ever get used as a work vehicle to earn income?*

Examples include:

  • making deliveries
  • transporting paying passengers
  • use as a work vehicle for real estate agents, tradespeople etc

2.1 Damage to the vehicle

Is there any damage to your vehicle?

Is the vehicle drivable?*

Was the vehicle towed from the scene?*


You may find a repairer from our preferred repairer list HERE

Please draw where the damage has occurred on your car

3.0 Third Party Damage

Were there any other vehicles involved in accident?*

Vehicle 1

Was the third party known to you prior to the accident?*

Was there another vehicle involved in accident?*

Vehicle 2

Was the third party known to you prior to the accident?*

Did the accident cause any damage to property (i.e. fences, walls, posts, etc.)*

4.0 What Happened

Click on map to add up to 2 pins

What lighting conditions applied at the time of the accident?*

What weather conditions applied at the time of the accident?*

Was the road Sealed or Metal?*

What were the road conditions at the time of the accident?*

Were there any passengers in your vehicle at the time?*

Were there any additional passengers?*

Additional Passengers

What speed were you travelling prior to the accident? km/hr*

Did either party admit liability?*

Has anyone been charged with any offence in connection with the accident?*

Were there any independent witnesses (not passengers of your vehicle)?*

Were there any other witnesses (Not passengers of your vehicle)?*

4.1 Police Details

Have the police been notified?

Did the Police attend the scene?

5.0 Images

Please attach the following:

  • License photo (front and rear) for both the driver and insured person
  • Scene photos
  • Vehicle damage photos (including other party's vehicle or property)

Anything else you consider relevant e.g. other party's License

Add Image

View Summary?*

6.0 Declaration (Please read this carefully before submitting)

I/We declare that:

  • All the statements in this claim form and any additional schedules are correct.
  • The motor vehicle and/or accessories are correctly described in this form and were lost, stolen or damaged under the circumstances described within this form.
  • I/We have told 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 Club Auto or TOWER to enable it to evaluate my/our claim.
  • I/We have certain rights of access to and correction of the personal information provided by me/us on this claim form or in support of 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 payment is subsequently recovered I/we will notify Club Auto or TOWER immediately and return the property to Club Auto or TOWER or will refund to Club Auto or TOWER the value of the recovered items.

I/We authorise Club Auto or TOWER to obtain personal information about me/us from any other party.

I/We authorise the New Zealand Police to release to Club Auto or TOWER copies of any or all documents held by the New Zealand Police relating to the incident giving rise to this claim and authorise Club Auto or TOWER to provide information about this claim and the insured to the New Zealand Police to assist with the police investigation. I/We consent to Club Auto or TOWER making a formal request pursuant to the Official Information Act, 1982 if necessary.

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