Notice of Claim Form

1 Contact Details 2 Insurance Details 3 Damage Details 4 Preferred Contact Time 5 Your Submission

Contact Details

In order to complete this Notice of Claim Form, you will need to provide your contact details, private insurance details, and a description of the natural disaster damage that has occurred. If you are not the Insured for this property you will need to provide the policy holder's details.

The information provided in this form will be used for the purposes of fulfilling EQC’s functions under the Earthquake Commission Act 1993, including managing, assessing and settling your claim. It may also be used for training, research, and statistical purposes.

For more information about how EQC manages customer information, please see our Privacy Policy.

First Name *

Surname *

Phone Number *

Email

If an email address is provided, you will receive an email notification that notice of your claim has been received.

Contact Address

Address Line 1 *

Address Line 2

City/Town *

Postcode

Are you the person named on the insurance policy for the damaged property? *

Yes

No

What is your relationship to the Insured party? *

Insurance Details

If you have damage to contents, please provide information about your contents insurance.
If you have damage to land or dwelling, please provide information about your dwelling insurance.

Address of the Policy Holder

Address Line 1 *

Address Line 2

City/Town *

Postcode

Contents Insurance

Private Insurance Company Name

Name of the Policy Holder

Policy Number if known

Dwelling Insurance

Private Insurance Company Name

Name of the Policy Holder

Policy Number if known

Preferred Contact Time

What is your preferred time of contact? *

Your Submission

Submitting your details...

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Page last updated: 1 May 2017

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Notice of Claim Form