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Crown Insurance Claim Form




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Please complete all of this form in full. If you have any questions, please contact us on 0800 246 787.
Claimant Details
Claimant's Name*
Claimant's Business / School Name*
Claimant's Email (reply to address)*
Claimant's Phone No.
User Details
User Name*
User's Parent or Guardian's Name
User's Date of Birth* Date Selector
Postal Address
User's Phone No.
Email
Device Details
Product Description (make and model)*
Serial No.*
If Acer Device, SNID No.
Loss or Damage Details
Date of Loss or Damage* Date Selector
Address where damage or loss occurred*
Describe in detail how the loss or damage occurred*
If damaged, describe in detail what the damage is*
Detail any other insurance relating to this loss
Name any other person(s) involved, if appropriate
When an item has been stolen this must be reported to the police and a Police Acknowledgement Form is required
Were the police notified*
Yes
No
If 'Yes', please upload the police acknowledgement form
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Declaration/ Privacy Act 1993 / Insurance Claims Register
I/We declare that:
  • All the answers in this claim form and on any attachment are complete and correct;
  • I/We have told Autosure about every matter that I/we know (or could reasonably be expected to know); and
  • I/We agree to give any further information that may be required.
I/We authorise:
  • Autosure to place details of this claim on the database of Insurance Claims Register Limited (ICR Ltd) PO Box 474 Wellington, where it will be retained and available to other insurance companies to inspect;
  • Autosure to obtain from any person or organisation, any information required to perform or complete any of the purpose in connection with which I/we have provided personal information to them; and
  • Any such person to release to Autosure any personal information that the person holds concerning me/us that is relevant for the purposes that they are seeking the information.
I/We acknowledge that:
  • Personal information concerning me/us provided to Autosure, and its related or associated companies and my/our intermediary, whether contained in this claim form or otherwise obtained is provided and may be held, used and disclosed by Autosure and my/our intermediary and other relevant parties;
  • Failure to provide any relevant information may result in your claim being declined or the policy being avoided;
  • The information provided in this claim form is held by Autosure, PO Box 33 1428, Takapuna, Auckland 0740 and my/our intermediary; and
  • I/We have the right under the Privacy Act 1993 to request access to and to request correction of any personal information concerning me/us, held by Autosure, my/our intermediary, ICR Ltd and other relevant parties.
Signature of the policy holder(s)
First Policyholder Signature
Your Full Name*
electronic signature by checking the box*
By checking this box, I am proving my electronic signature and hereby acknowledge that I agree to the above declaration
Second Policyholder Signature
Your Full Name
By checking this box, I am proving my electronic signature and hereby acknowledge that I agree to the above declaration