Prototype Home Claims Form

This form is a prototype to be used by the testing party only.
Any information will not be submitted to AMP Claims.

Important Information

We can use the information you give us to assess and manage your claim so it's important that this information is true, complete, and accurate. If it's not, we might decline your claim and cancel your policy.

For more details on how we use your personal information, read our Privacy Statement

Please enter the following details

Policyholder details

Claims details

Details of items being claimed for

Add photos and/or documents

To help us process your claim faster, attach documents like: photos, receipts, etc.

Please note: A limit of 5MB per file. A maximum of files totally 50MB can be uploaded. File types supported: JPEG, PNG, TIFF, GIF, PDF, TXT, Excel and Word

    Direct crediting authority

    I/We authorise the payment to be made into this bank account

    Declaration/Privacy Act 1993/Insurance Claims Register

    I/We declare that to the best of my/our knowledge and belief these particulars are complete and correct.


    1. agree to give any further information that may be required;
    2. understand you require this personal information, which will be retained by you at 48 Shortland Street, Auckland before you can evaluate my/our claim;
    3. authorise the disclosure of this personal information regarding this claim to other parties;
    4. authorise the obtaining by you from any other party personal information about me/us that is in your view relevant to this claim;
    5. authorise the obtaining by you from Insurance Claims Register Limited (ICR Ltd), which holds details of claims made by me/us under policies with other insurers, personal information about me/us that is in your view relevant to this claim;
    6. authorise you to place details of this claim on the database of ICR Ltd, PO Box 474, Wellington, where it will be retained and be available to other insurance companies to inspect;
    7. understand that I am/we are entitled to have certain rights of access to and correction of the personal information held by you and ICR Ltd.

    The collection of this information is required under the terms of your policy. Failure to provide it may result in your claim being declined.