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Select Claim Type

Please choose the type of claim.

Claim Type

Material Damage Claim Form

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Vehicle Claim Form

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Liability Claim Form

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Home and Contents Claim Form

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Step 1 – Insured / Company Details

Unfortunately The Unexpected Does Happen!
Please complete your claim form so that we can get your claim moving!

This form collects personal information about you so that the insurer can evaluate your claim. Failure to provide this information may result in your claim being declined. The collection of this information is required as part of the terms of your insurance policy. It will be held by Marble Insurance and the insurer who received your claim. You have the rights of access to and correction of this information subject to the provisions of the Privacy Act 2020. Click here to view our full Privacy Statement.

Important notice

You must answer all questions honestly and fully. The issue of this claim form is not an admission of liability.

How to complete this form

To help us process your claim as quickly as possible, please answer all questions honestly and in full. If a question does not apply to your situation, please enter “N/A”.
Ensure that all information provided is accurate before proceeding to the next step. You can move through the form using the Next and Previous buttons.
Once all sections have been completed, please review your answers carefully and submit the form. If additional information is required, your broker or insurer may contact you.
The signed form should then be posted, or emailed, to your broker.

Insured Information

Your Insured Name And/Or Company Name *

Insured Information

Contact Person *

Insured Information

Policy Number (If known)

Address

Full Address *

Insured Information

Email *

Insured Information

Phone *

Claim Details

What is this claim for? *

Commercial Building

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Business contents (tools, stock, etc.)

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Claim Details

What happened? *

Damage

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Malicious Damage

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Theft

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Burglary

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Accidental damage

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Malicious Damage

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Theft

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Burglary

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Claim Details

When did the incident happen? *

Claim Details

Where did the incident happen? (Full address)

Claim Details

Please provide details of the incident *

Loss Reduction Details

Have you done anything to reduce or recover the loss or damage? *

Yes

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Loss Reduction

If 'Yes' please explain details below: *

Witness Details

Were there any witnesses? *

Yes

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Witness Details

If 'Yes', please provide witness details below:

Witness

Name * Phone Number * Email *

Responsibility Details

Do you think that any other person is responsible for the loss or damage? *

Yes

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Responsibility Details

If 'Yes' please provide details below: *

Police Report

Is a Police Complaint Acknowledgement attached? *

Yes

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Police Report

Police Complaint Acknowledgment * Or email us at claims@marbleinsurance.co.nz

Police Report

Reported by *

Police Report

Date *

Police Report

Station Name *

Police Report

Complaint Ref No *

Police Report

Name of Attending Officer *

Other Insurance Details

Do you have any other insurance which covers this loss or damage? *

Yes

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Other Insurance Details

If 'Yes' please give details *

Past Claims Details

Have you claimed on any type of property insurance in the past 5 years? *

Yes

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Past Claims Details

If ‘Yes’ please give full details (include date, type of claims and name of Insurer): *

Past Claims Details

Do you have a Schedule of Loss to attach? *

Yes

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No, But I will provide at a later date

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No, I will provide details below

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Past Claims Details

Attached Copy of Schedule of Loss * Or email us at claims@marbleinsurance.co.nz

To support ownership and the amounts claimed, please attach receipts, valuations, guarantees, current quotations or other documents. If repairs have been paid for, please attach a receipt or account. Wilful or reckless exaggeration of any amount claimed will forfeit the claim. If at all possible, keep damaged items available so that we can inspect them if needed.

Past Claims Details

Schedule of Loss

Item

Description of Item (include make, model and serial #) * From whom Obtained (name and address) * Date Obtained * Current Replacement Cost * Repair Cost *

Ownership Details

Are you the sole owner of the lost or damaged property? *

Yes

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Ownership Details

Owner's name *

Ownership Details

Owner's Full Address *

Ownership Details

Owner's Phone *

Finance Details

Is any of the lost or damaged property subject to any financial or hire purchase agreement? *

Yes

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Finance Details

Company name *

Finance Details

Company Full Address *

Finance Details

Company Phone Number *

Occupancy Details

Who occupies the building? *

Tenant

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Owner Occupied

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Unoccupied

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Occupancy Details

Tenant Name

Occupancy Details

Phone

Insured Vehicle

Make *

Insured Vehicle

Year *

Insured Vehicle

Model *

Insured Vehicle

Licence Plate *

What is this claim for? *

Damage

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Theft

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Vehicle / Ownership

Registration number *

Vehicle / Ownership

Purchased from *

Vehicle / Ownership

Date purchased *

Vehicle / Ownership

Purchase price (NZD) *

Vehicle / Ownership

Have you offered the vehicle for sale, sought valuations or trade-in estimates during the past 12 months? *

Yes

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Vehicle / Ownership

If ‘Yes’, from whom, why and with what result? *

Vehicle / Ownership

Is the insured the registered owner of the vehicle? *

Yes

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Vehicle / Ownership

If ‘No’, who is the registered owner? *

Vehicle / Ownership

Is money owed on the vehicle to any person or firm? *

Yes

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Vehicle / Ownership

If ‘Yes’, please provide details *

Person in Charge

Who was the last person in charge of the vehicle before it was stolen? *

Insured

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Other

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Person in Charge

Full Name *

Person in Charge

Full Address *

Person in Charge

Phone number *

Person in Charge

Email address *

Person in Charge

Relationship to the insured *

Person in Charge

Age *

History

Have you ever been refused motor vehicle insurance or had a policy cancelled by an insurer? *

Yes

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History

Please provide details *

History

Within the past five years, have you had a motor accident, including broken glass, fire or theft? *

Yes

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History

Please provide details including date(s), costs and insurer *

History

Within the past five years, have you had a conviction, pending prosecution or been fined for a motoring offence (other than parking)? *

Yes

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History

Please provide details (including penalties) *

History

Have you previously had a vehicle stolen? *

Yes

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History

Please provide details *

Police Report

Name of the Police Station to which the theft was reported *

Police Report

Name of Police Officer *

Police Report

When was the theft reported? *

Police Report

Police file number *

Police Report

Please attach the Police Complaint Acknowledgement form Or email us at claims@marbleinsurance.co.nz

Theft Details

Date & time the vehicle was left *

Theft Details

Date & time the theft was discovered *

Theft Details

Location the vehicle was stolen from * Please provide a full description

When you left your vehicle:

Where were you going? *

When you left your vehicle:

Who was with you? (Name) *

When you left your vehicle:

Who was with you? (Phone) *

When you left your vehicle:

Who was with you? (Full Address) *

When you left your vehicle:

Who was with you? (Email address) *

When you discovered the theft:

Who was with you? (Name) *

When you discovered the theft:

Who was with you? (Phone) *

When you discovered the theft:

Who was with you? (Full Address) *

When you discovered the theft:

Who was with you? (Email address) *

Theft Details

How did you get home? *

Vehicle Security

Were all the vehicle doors locked? *

Yes

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Vehicle Security

Were all the windows fully wound up? *

Yes

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Vehicle Security

Were the keys in the ignition or in/about the vehicle? *

Yes

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Vehicle Security

Please provide full details *

Vehicle Security

How many sets of keys do you have and where are the keys now? *

Theft Details

Does the vehicle have any form of additional security (e.g. alarm, steering lock)? *

Yes

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Theft Details

Please provide full details *

Theft Details

Was such security being used? *

Yes

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Theft Details

Has the vehicle been recovered? *

Yes

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Theft Details

Where was it found and by whom? *

Theft Details

Date & time the vehicle was found *

Theft Details

Who arranged salvage? *

Theft Details

Name of Police Station and Officer attending *

Theft Details

Damage to vehicle *

Theft Details

Current location of the vehicle *

Theft Details

Arrangements for our inspection *

Theft Details

Did you have any personal effects stolen? *

Yes

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Theft Details

What personal effects were stolen? *

Theft Details

Which company are your contents insured with? *

Vehicle Condition

Speedometer reading * Please include unit eg. km/miles

Vehicle Condition

Condition of paintwork *

Vehicle Condition

Condition of interior trim *

Vehicle Condition

Motor / transmission (details of major works and cost since purchase) *

Vehicle Condition

Condition of body panels (rust or dents) *

Vehicle Condition

Age of tyres – Left Front *

Vehicle Condition

Age of tyres – Right Front *

Vehicle Condition

Age of tyres – Left Rear *

Vehicle Condition

Age of tyres – Right Rear *

Vehicle Condition

Accessories on vehicle when purchased *

Vehicle Condition

Accessories fitted since purchase *

Vehicle Condition

Who normally services the vehicle? *

Vehicle Condition

When was the last WOF issued? *

Vehicle Condition

WOF issued by *

Vehicle Condition

What do you consider the vehicle’s market value at the time of theft? (NZD) *

Vehicle Condition

What do you base this opinion on? *

Stolen / Damaged Accessories

Please list any accessories stolen or damaged *

Accessory

Item * Date Purchased * Place Purchased * Purchase Price * Replacement Cost *

Insured Vehicle

At the time of the accident was the vehicle being used for business or carrying any goods? *

Yes

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Business Use

If 'Yes', please provide full details *

Insured Vehicle

Was your vehicle damaged? *

Yes

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Repairer

Do you know the repairer you are going to use at this time? *

Yes

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Repairer

Repairer Company Name *

Photos

Photo(s) of damage to your vehicle * Please upload images only. Each file must be less than 5MB.

Details of Driver / Person in Charge

Who was driving the vehicle? *

Driver / Person in Charge

Date Of Birth *

Driver / Person in Charge

Driver Full Address *

Driver / Person in Charge

Phone *

Driver / Person in Charge

Type Of License *

Full

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Restricted

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Learners

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Driver / Person in Charge

Class Of License *

Car

Class 1

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Medium Rigid Vehicle

Class 2

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Medium Combination Vehicle

Class 3

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Heavy Rigid Vehicle

Class 4

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Heavy Combination Vehicle

Class 5

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Motorcycle

Class 6

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Driver / Person in Charge

Driver License Number *

Driver / Person in Charge

Driver License Version *

Driver / Person in Charge

License Expiry Date

Driver / Person in Charge

Are you the policy holder? *

Yes

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Driver Relationship

What is your relationship to the policy holder? *

Driver Relationship

Was the vehicle being driven with the owners consent? *

Yes

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In the past five years has the driver?

Had any losses / incidents involving damage or theft of a vehicle (excluding glass)? *

Yes

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In the past five years has the driver?

Been disqualified from driving or had licence suspended or cancelled *

Yes

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In the past five years has the driver?

Been convicted of any offence other than parking or speeding *

Yes

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In the past five years has the driver?

Has the driver had any insurance refused, cancelled, special terms imposed or had a claim declined in the last five (5) years *

Yes

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Past Losses Details

If yes please provide details *

Incident Details

Date & Time *

Incident Details

Where did the incident happen? *

Traffic Controls

Was a Stop sign present at the scene? *

Yes

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Unsure

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Traffic Controls

If present, were they in your favour? *

Yes

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Traffic Controls

Was a Give-way sign present at the scene? *

Yes

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Unsure

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Traffic Controls

If present, were they in your favour? *

Yes

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Traffic Controls

Were Traffic lights present at the scene? *

Yes

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Unsure

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Road Conditions

Was the road wet at the time of the accident? *

Yes

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Incident Details

Please describe how the accident occurred *

Fault

Was the accident your fault? *

Yes

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Fault

Why do you believe this? *

Third-party damage

Were any other vehicles or property involved in the accident? *

Yes

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Third-party damage

Name of Driver / Owner of the other vehicle or property *

Third Party Address

Third Party Full Address *

Third-party damage

Contact number(s) *

Third-party damage

Type Of Vehicle / Property *

Third-party damage

Their insurance company's details

Third-party damage

Photo of damage to third party Images only. Max 5MB per file.

Authorities & Witnesses

Was the accident reported to the Police? *

Yes

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Was any intoxicating liquor and/or drugs consumed by the driver in the 12 hours prior to the accident? *

Yes

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If ‘Yes’, please provide details (time, volume/quantity and place of consumption) *

Was a breathalyser, blood test or any other test requested? *

Yes

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If ‘Yes’, what was the result? *

Were there any other passengers in your vehicle or any other witnesses? *

Yes

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Passengers / Witnesses

Claim Details

Where did it happen? * (Full Address)

Claim Details

When did it happen? *

Claim Details

How did it happen? *

Witness Details

Were there any witnesses? *

Yes

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Witness Details

If ‘Yes’, please provide witness details below:

Witness

Name * Phone Number * Email *

Injury or Damage Details

Was the property under your care, custody or control? *

Yes

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Injury or Damage Details

Had you previously agreed to be responsible for any such damage? *

Yes

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Injury or Damage Details

Who owns the damaged property? * Please give full details

Injury or Damage Details

Was the damaged property insured? *

Yes

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Don't Know

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Injury or Damage Details

Name of the Insurance Company *

Injury or Damage Details

Have you done anything to reduce or make good on the loss or damage? *

Yes

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Injury or Damage Details

If ‘Yes’, please explain details below: *

Claimant Details

Has any claim been made against you in connection with this accident? *

Yes

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Claimant Details

Full Name / Company Name *

Claimant Address

Claimant Full Address *

Claimant Contact

Phone

Claimant Details

Please select if any of these apply to the claimant *

Related to you

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Employed by you

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A member of your household

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Your agent

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Your neighbour

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Your landlord

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Not Applicable

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Claimant Details

Have you received any written notice or correspondence about the claim? *

Yes

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Claimant Details

If ‘Yes’ please attach copy below: Or email us at claims@marbleinsurance.co.nz

The Claim Incident

What is this claim for? *

House Claim

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Contents Claim

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The Claim Incident

What happened? *

Burglary

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Theft

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Loss

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Damage

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Malicious Damage

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Accidental damage

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The Claim Incident

When did the incident happen? *

The Claim Incident

Did the incident happen? *

Yes

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Incident Location

Incident Full Address *

The Claim Incident

Please provide details of the incident *

Witness Details

Were there any witnesses? *

Yes

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Witness Details

If ‘Yes’ please provide witness details below.

Witness

Name * Phone Number * Email *

If a burglary: Please state means of entry *

Was the loss caused by a person other than yourself? *

Yes

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Person Details

Full Name * Full Address * Phone *

Was the damage caused by gaining entry? *

Yes

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If ‘Yes’, what damage was caused? *

Policy Details

Is a Police Complaint Acknowledgement attached? *

Yes

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Police Complaint Details

If 'Yes' please attach a copy of the Police Complaint Acknowledgement. * Or email us at claims@marbleinsurance.co.nz

Police Complaint Details

Reported by – Full Name *

Police Complaint Details

Date *

Police Complaint Details

Station Name *

Police Complaint Details

Complaint Ref. No: *

Police Complaint Details

Name of Attending Officer *

Police Complaint Details

Was a list of missing items given to the Police? *

Yes

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Please note we may request a copy of this from the Police.

General Questions

Do you have any other insurance which covers this loss? *

Yes

✔

General Questions

If ‘Yes’ please give details. *

General Questions

Are you the sole owner of the property? *

Yes

✔

General Questions

Owner’s Full Name *

General Questions

Owner’s Full Address *

General Questions

Owner’s Phone *

General Questions

Is the property subject to any financial or hire purchase agreement? *

Yes

✔

Company Details

Company Name *

Company Details

Company Full Address *

Company Details

Company Phone *

Property

Who occupies the property? *

Owner occupied

✔

Tenant

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Unoccupied

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Tenant Details

Tenant Full Name *

Tenant Details

Phone *

General Questions

Have you made any other insurance claims over the last five years? *

Yes

✔

General Questions

If ‘Yes’ please give full details. *

General Questions

Have you or any member of your family ever had an insurance claim declined? *

Yes

✔

General Questions

If ‘Yes’ please give full details (include date, type of claims and name of Insurer). *

General Questions

Have you or any member of your family living with you, ever been charged or convicted of any criminal offence other than driving offences? *

Yes

✔

General Questions

If ‘Yes’, please give details below. *

General Questions

Have you ever had an insurance policy declined, or had special terms imposed? *

Yes

✔

General Questions

If ‘Yes’, please give details below. *

Details of Claimed Items

Do you have a Schedule of Loss to attach? *

Yes

✔

No, I will provide at a later date

✔

No, I will provide details below

✔

Schedule of Loss

If ‘Yes’, please attach a copy of the Schedule of Loss. * Or email us at claims@marbleinsurance.co.nz

Schedule of Loss – Instructions

To support ownership and the amounts claimed, please attach receipts, valuations, guarantees, current quotations or other documents.

If repairs have been paid for, please attach a receipt or account.

Wilful or reckless exaggeration of any amount claimed will forfeit the claim.

If at all possible, keep damaged items available so that we can inspect them if needed.

A. Schedule of Loss – Items lost or damaged beyond repair

Item

Full description (include make, model and serial #) * Date obtained * From whom obtained (name and address) Price paid Current Replacement Cost Name of Repairer Estimated repair cost

Bank Details

Would you like to add your bank details? *

Yes

✔

Bank Details

NZ Bank Name *

Bank Details

NZ Account Number *

Declaration

I/We declare that to the best of my knowledge the details provided in this claim form are true. I/We have not withheld any information likely to affect the insurers consideration of the claim.

I/We agree to Marble Insurance Limited and the Insurance Company (and/or their agent) with whom I am insured may disclose my/our personal information regarding this claim to:

a. Other parties including other members of the Insurance Industry and the data base of the Insurance Claims Register (ICR Ltd) PO Box 474, Wellington where it will be retained and made available to other insurance companies to inspect.

b. Parties who have a financial interest in the subject matter of the policy and parties repairing or replacing the subject matter of the claim.

c. I/We understand that I am/we are entitled to have certain rights of access to and correction of the personal information held by Marble Insurance Limited and the Insurer and ICR Ltd.

d. I/We understand that my/our personal information may be provided to overseas third party service providers and/or Insurers who may use this information either on our behalf or otherwise to process and evaluate the claim.

I/We agree to Marble Insurance Limited and the Insurer obtaining personal information about me/us that is, in their view, relevant to this claim. From any other party including other members of the Insurance Industry and from Insurance Claims Register Ltd (ICR) which holds details of claims made by me/us under policies with other insurers.

All information and answers (whether written or oral) given to Marble Insurance Limited and the Insurance Company in connection with this claim are correct and that no information relevant to the claim has been omitted. I/We authorise Marble Insurance Limited and the Insurance Company to act on my/our behalf.

Declaration Details

I [Name] am completing the declaration? *

Yes

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Declaration Details

Full Name *

Declaration Details

Signature *

Draw your signature below: