Esure Insurance Brokers  

Equity Insurance Brokers Ltd
GRAEME L. JOHNSTON
PO Box 24-348, Royal Oak, Auckland, New Zealand.
Ph: +64 9 623 3233,
Fax: +64 9 623 1177
Mobile: +64 21 995 355
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DANA J. KERR
Email: dana@esure.co.nz
PO Box 1335, Hamilton, New Zealand
Ph: +64 7 834 3340
Fax: +64 7 838 2446

VEHICLE CLAIM FORM

PLEASE NOTE: This is not an official insurance claim form. We are simply gathering enough information to lodge your claim with the Insurer until they request further details.
 
1. Name: *
2. Email Address: *
3. Phone No: *
4. Company (If applicable):
5. Policy No.: *  
6. Date of Loss or incident:
7 How and where did the loss or damage happen?
8.
Vehicle: Type Registration Number Current Sum Insured $ Repair Estimate $
 
 
9. Where is the vehicle now?
10. Briefly Describe Extent of Damage:
11. Do you think any other person is responsible for the loss or damage? Please give your reasons:

* Required Fields to be filled in.