UNINSURED THIRD PARTY INSURANCE CLAIM FORM

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					                                                                                               For Office Use Only:
Policy Number                                                                                  Claim Number




                       UNINSURED THIRD PARTY INSURANCE CLAIM FORM
                Please complete all Sections, or draw a line through any question which does not apply

                                        Section One - Our Policy Holder Details
Surname:                                  First Name:                         Middle Name:                         DOB:
Address:                                                                                       Town, City or District:

Home Phone No:                                        Work Phone No:                           Cellphone No:



                                             Section Two – Our Driver’s Details
Surname:                                  First Name:                         Middle Name:                         DOB:
Address:                                                                                       Town, City or District:

Home Phone No:                                        Work Phone No:                           Cellphone No:
Were there any passengers in the car?           Yes        No      If YES, state the names, address and phone numbers:
Name:                                                                   Name:
Address:                                                                Address:
Phone:                                                                  Phone:


                                             Section Three – Our Vehicle Details
Registration No:                          Make:                               Model:                       Year:


                                          Section Four – Third Party’s Details
Surname:                                  First Name:                         Middle Name:                         DOB:
Address:                                                                                       Town, City or District:

Home Phone No:                                        Work Phone No:                           Cellphone No:
Were there any passengers in the car?           Yes        No      If YES, state the names, address and phone numbers:
Name:                                                                   Name:
Address:                                                                Address:
Phone:                                                                  Phone:


                                       Section Five – Third Party’s Vehicle Details
Registration No:                              Make:                           Model:                      Year: CC Rating:
Is your vehicle financed? Yes     No          Finance Company:                                            Contract No:
Do you have any insurance policy on your vehicle? Yes            No
If YES, please state   Name of Company:
                       Address of Company:
                       Your Policy Number:


                                              Section Six - Details of Accident
Date:                                         Day:                            Time:                             am           pm
Location: (state street or intersection name(s) and town accident occurred)
What speed were you travelling?                                         Kph
What speed do you think the other driver was travelling?                 Kph
What were the road conditions? eg sealed, metal, other?



Full Description of Accident:
                         Sketch of Accident - Please mark your vehicle with X and the other vehicle etc with O




                                                                                                            Please show:
                                                                                                                      Street Names
                                                                                                                      Road Markings
                                                                                                                      Road Signs
                                                                                                                      Traffic Signals
                                                                                                                      Traffic Islands
                                                                                                                      Distances from kerb
                                                                                                                      Distances between vehicles
                                                                                                                      Direction of travel

Which driver do you consider to be at fault?

What are your reasons?




                              Section Seven - Police Officer Details (if applicable)
Did a Police Officer attend the scene of the accident? Yes       No       If YES, please complete Officer details below:


Officer’s name:                        Officer’s QID No:                       Officer’s Station:                     File Number or Event No:




                                   Section Eight – Details of Damage to Vehicle
Please provide details of damage to your vehicle. Use the diagram to indicate damage, eg damage to left front and bonnet




Did the vehicle require towing?            Yes        No

If YES, please provide the name and address of the tow company          Please provide the location of the vehicle at present



Have quotes been obtained? If so, please attach                         Panelbeater’s Name:


                                                                        Estimated Cost of repair:
                                                Section Nine – Driving Conditions

      For each of the following categories, circle the number(s) that best describes the conditions at the time of the accident


     Type of Accident                 Weather                 Road                Road Type                   Vehicle Was                 Damage to
                                     Conditions             Conditions                                                                     Vehicle
1 Other party hit us            1   Fine                                     1 Open road                1 Stationary
2 We hit another vehicle        2   Overcast            1   Dry              2 70 km/h zone             2 Moving off                  1   Front
3 Hit cyclist                   3   Raining             2   Wet              3 50 km/h zone             3 Slowing down                2   Rear
4 Hit pedestrian                4   Strong wind         3   Flood            4 Intersection             4 Overtaking                  3   Driver’s side
5 Hit stationary object         5   Poor visibility     4   Slippery         5 Private property         5 Changing lanes              4   Passenger’s side
6 Hit animal                    6   Glare               5   Icy              6 Company premises         6 On a roundabout             5   Bonnet
7 Vandalism                     7   Snow or ice         6   Muddy            7 Car park                   /intersection               6   Roof
8 Theft                                                 7   Unsealed         8 Farm                     7 Making a U turn             7   Multiple
9 Windscreen                                                                 9 Forestry                 8 Reversing                   8   None
10 Driver lost control                                                       10 Motorway                9 Unattended
                                                                                                        10 Proceeding normally



                                             Section Ten – Additional Information
                                              Please provide any other information you feel relevant




                                                      Section Eleven – Declaration

I, ________________________________________________________ (driver), declare that the information and answers given above are
true in every detail and that all relevant information has been disclosed.
I/We understand that provision of this form and completion of the form does not constitute any admission of liability by Pioneer Insurance either
under their policy holder’s insurance policy or otherwise.
I/We authorise the insurer to give to, or obtain from any other party, any information that in the insurer’s view, is relevant to this claim.
I/We understand that:
           The claim may be refused if information is untrue or concealed
           The information is needed before the insurer can decide whether to accept this claim
           The Privacy Act 1993 entitles me to have access to and, if necessary, request correction of information


Signature of Driver:                                                                   Date:




Signature of Policy Holder:                                                            Date:




When you have completed all the necessary details:
Fax the claim form to:                                   Napier (06) 834 3634
Or
Post to:                                                 Pioneer Insurance, Motor Claims Department, PO Box 1056, NAPIER
                                    Section Twelve – Statutory Declaration


TO BE COMPLETED BY THE REGISTERED OWNER OF THE UNINSURED VEHICLE.


REGISTRATION PLATE: ___________________________________




I, _______________________________________________ OF ______________________________________________________


Solemnly and sincerely declare that at the time of the accident my motor vehicle was not insured in any way whatsoever.


        This vehicle is subject to security / finance by ________________________________________________________

        Is not subject to any security / finance.




I make this solemn declaration conscientiously believing the same to be true and by virtue of the Oaths and Declarations Act 1957.




Signed: _________________________________________________
        (registered owner of the uninsured vehicle)


Declared at: _______________________________________ this _________ day of ________________ 20________.




Signed: ___________________________________________________________
        Justice of the Peace (or any person authorised to take a Statutory Declaration)




Note: Section III of the Crimes Act 1961 makes liable to imprisonment for a term not exceeding three years
every person who, on any occasion on which he is required or permitted by law to make any declaration before any
person authorised by law to receive it, makes a declaration that would amount to perjury if made on Oath in a
judicial proceeding.