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

Policy number*

Full name*

Additional policyholder full name

Contact email*

Mobile number*

Date of Birth*

Postal Address*

Claims details

Date of loss*

Time of loss*

Location where loss or incident occurred*

Please state the full details of what happened*

Details of items being claimed for

What area/s have been damaged?*

What is the damage?*

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

If your claim is accepted and there are payment(s) to you, we can pay this amount direct into your bank account by direct credit. If you would like us to make this direct credit, please complete details below. You will be advised if a payment has been made following acceptance of your claim.

Do you wish to use this facility?*

Yes

Name of the Account*

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

Bank number (2)

Branch number (4)

Account number (7)

Suffix (2 or 3)

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.

I/We

agree to give any further information that may be required;
understand you require this personal information, which will be retained by you at 48 Shortland Street, Auckland before you can evaluate my/our claim;
authorise the disclosure of this personal information regarding this claim to other parties;
authorise the obtaining by you from any other party personal information about me/us that is in your view relevant to this claim;
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;
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;
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.

By clicking here, I state that I have read and understood the Declaration/Privacy Act 1993/Insurance Claims Register