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Motorcycle Claim Form

1. Insured Details

Policy Number

Name of Insured

First Name(Required)

Last Name(Required)

Your Email(Required)

Best contact number(Required)

Postal Address(Required)

Authorised Contact

Authorised Contact Name

Authorised Contact Number

Authorised Contact Email

Relationship to Insured

2. Goods and Services Tax

Are you registered for GST?

What is your entitlement to an input Tax Credit in respect of

Your Motorcycle insurance premium

The property that is the subject of this claim

3. Motorcycle Details

Type

Year

Make

Model

Registration Number

(VIN) / Chassis number

List of modifications or accessories

Finance on Motorcycle, if yes, name of lender

Purchase Price

Purchase Date

Are you the Owner of this bike

If no please provide details

Did the Motorcycle have any pre-existing damage

If yes please provide details

4. Type of Claim

Claim Type(Required)

Please describe what happened

Upload: Any Videos or Photos of the Incident, Photos of your damage, Photos of other damage, Quotations, Demands

Drop files here or

Max. file size: 6 MB.

5. Claim Details

Date of the Accident(Required)

Time of the Accident

:

Location of Accident

Estimated speed at the time of accident

Road surface

Weather

Light Conditions

What was the motorcycle being used for

Is the Motorcycle still Rideable

Current location of motorcycle

Was the motorcycle towed or Transported

Please provide contact details of tow company if applicable

Was liability admitted by any party?

If yes who

Who do you believe was responsible for the incident

6. Rider Details

Name Of Rider

Date of Birth

Licence Number

Licence Expiry

Is The Rider the Insured

Rider – Years of experience

7. Police Details

Did the Police Attend

If yes please provide Station and Officers Name

Police Reference Number / Report Number

If police did not attend, was the incident reported?

Were any Alcohol/drugs, prescriptive or non-prescriptive medication consumed 12 hours prior to the accident?

If yes, what was consumed and how much

Did police order a breathalyser or blood test?

If yes what was the reading

Was anyone charged for this accident?

If yes who was charged and what was the charge

8. Other / Third Party Details

Third Party Name

Third Party Address

Third Party Phone Number

Third Party Email Address

Third Party Vehicle Details

Third Party Registration

Third Party Licence Details

Name of Third Party Insurance company

Policy / Claim Number

Have you received any demands

If Yes, please provide details

If there are any other parties involved, please advise below

9. Witness Details

Name of witness

Witness Address

Witness contact number

Witness email address

Where was the witness when they saw the accident

10. Disclosure Questions

Has the Insured had any insurance refused or cancelled?

If yes, please provide details

Has the Insured been charged or convicted of any offence If yes, please provide details in the last 5 Years (other than vehicle/motorcycle offences)?

If yes, please provide details

How many at fault motorcycle accidents or at fault motorcycle claims has the Insured made in the last 3 years?

If yes, please provide details

Has the Insured made any motorcycle theft claims in the last 3 years?

If yes, please provide details

Has the Insured had any licence suspensions, disqualification or good behaviour periods in the last three years?

If yes, please provide details

Privacy

We are committed to protecting your privacy.

We are committed to protecting your privacy. We collect the personal information we need to assess insurance applications, provide quotations, issue insurance policies and assess claims made under them. We may not be able to do these things if you don’t provide the information we need.

We provide your personal information to the insurer that underwrites your insurance and our related companies. We provide your name and policy number to any intermediary that arranged your policy or referred you to us.

We may also provide relevant personal information to our trusted suppliers including financiers, loss adjusters, assessors, surveyors, repairers, professional advisers, document storage centres, data centres, third party providers, outsourcing partners located within or outside Australia and IT software/ service providers. Depending on the nature of your claim, we may also need to provide relevant personal information to authorities (such as the police, licensing and registration bodies and the Australian Financial Security Authority) and to other insurers in the event of recovery or litigated action.

We may use your contact details to send you marketing communications that we believe may be of interest to you. You can opt out from receiving these at any time.

If this Claim Form includes personal information such as names, addresses etc of any other person, you must ensure that you have that person’s consent to provide this information to us and that you provide them with the information in this Privacy Collection Statement as well as the link and/or information about how to access our Privacy Policy.

In the event of any inconsistency between this Privacy Statement and our Privacy Policy available on our website, the Privacy Policy will prevail.

“Our Privacy Policy contains more information about how we manage your information including how you can access it, ask us to correct it or make a privacy related complaint. This is available free of charge on our website and on request by telephone: 0800 455 003 or email: customerservice@nminsurance.co.nz”

Email

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Policy Wordings

National Motorcycle Insurance is a business name of Nautilus Marine Underwriting Agency Ltd NZBN: 9429031454261, FSP: 38832. Nautilus Marine Underwriting Agency is an insurance underwriting agency that has binding authority from Zurich Australian Insurance Limited (ZAIL) which allows it to enter into and arrange policies of insurance. Nautilus Marine Underwriting Agency acts on behalf of ZAIL and not you when providing these services but does so under its own FSP number.

Content on this website is information only and not financial advice. It is intended as a summary of the highlights of any cover available and does not take into account any person’s objectives, financial situation or needs. Always read the relevant Policy Wording before buying or renewing insurance. It contains a full description of the applicable terms and conditions.

Steadfast Group Ltd (ABN 98 073 659 677) (‘SGL’) has a majority shareholding in NM Insurance Pty Ltd (NM Insurance).

SGL may receive a professional services fee (PSF) from insurers, premium funders and underwriting agencies such as NM Insurance (Partner) for access to regulatory and compliance support; marketing and communications; data insights; and access to technology platforms. The PSF is an agreed amount between SGL and the relevant Partner, usually annually. The PSF is not determined by the volume of the business that the Steadfast Network brokers place, nor is the amount of the PSF known to the Steadfast Network Brokers, so it is not able to influence recommendations to their clients.

NM Insurance may have access to shared services from SGL, including: compliance tools; procedures; manuals and training; legal; HR banking; and group purchasing arrangements. These services are funded by SGL, subsidised by SGL or SGL receives a fee for them.

SGL’s FSG is available at www.steadfast.com.au or on request by telephoning SGL’s Company Secretary on +61 2 9495 6500.