House Insurance - AMI Insurance

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AMI House Insurance. 1. Premier House. M ts. House Insurance. Restriction Zone Supplementary Application. Customer information. Date: / /. Customer name:.
Premier House

Market Value House

House Insurance

House Construction

Premier Rental Property Insurance

Market Value Rental Property Insurance

Restriction Zone Supplementary Application Customer information Date:   /   /

  Customer name: 

Insured name (if different):  Preferred method of contact (phone or email details):  Customer reference: 

TotalCareMax Mortgage & and existing insurance Living Details of the home to be insured Income Protection Assurance

Injury Insurance

Location of the home to be insured: 

Do you already own this home?................................................................................................................................................................... yes 

Accident Insurance  no 

If ‘No’, please provide settlement date if known:   /   / Existing insurer of the home: 

Policy number: 

Is the property in a location identified by the council as being at increased risk of a natural hazard (other than earthquake), such as flooding or inundation, erosion or subsidence?

In approximately which year was the home built? (Note that additional information will be required for any home built before 1935):

Business Liability

Contract Works

Machinery Breakdown

Commercial Vehicle

Breakdown   Standard

Who will live in the home?  Has the property suffered any earthquake and/or liquefaction damage from the following events: 4 September 2010: ................................................................................................................................ Home? 

  Land?    No damage? 

22 February 2011: ................................................................................................................................... Home? 

  Land?    No damage? 

13 June 2011: ........................................................................................................................................... Home? 

  Land?    No damage? 

23 December 2011:................................................................................................................................ Home? 

  Land?    No damage? 

14 February 2016: ................................................................................................................................... Home? 

  Land?    No damage? 

14 November 2016: ............................................................................................................................... Home? 

  Land?    No damage? 

If the home has suffered damage please provide details below: Has a claim been lodged with EQC? For the dwelling?............................................ yes 

 no 

Claim number(s): 

For land damage?........................................... yes 

 no 

Claim number(s): 

Have / will entitlements under the vendor’s open EQC Claim(s) been / be assigned to you?.................................................... yes 

AMI House Insurance

 no 

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Details of damage and structures claimed for? 

Have any EQC claims for earthquake damage already been settled?............................................................................................. yes 

 no 

Claim number(s):  If ‘Yes’, was this by: 1. Managed repair?   2. Cash settlement? 

If managed repair, please provide evidence to support this (e.g. Code Compliance Certificate, statement of completion from tradesperson responsible, photos):

If cash settled, has the damage been completely repaired?................................................................................................................ yes 

 no 

If ‘Yes’, please provide evidence of repairs. If ‘No’, please advise your intentions regarding repairs or progress to date:

Has a claim been lodged with the insurer?............................................................................................................................................... yes 

 no 

Claim number(s):  Have / will entitlements under open claims on the vendor’s policy been / be assigned to you?.......................................... yes 

 no 

Details of damage and structures claimed for:

Please provide a copy of any agreements that have been entered into with this application. Have any insurance claims for earthquake damage already been settled?

yes 

 no 

Claim number(s):  If ‘Yes’, was this by: 1. Managed repair?   2. Cash settlement? 

If repair was managed by a different insurer (i.e. not with IAG, Southern Response or Lumley), please provide evidence to support completion of repairs. If cash settled, has the damage been completely repaired?............................................................................................................... yes 

 no 

If ‘Yes’, please provide evidence of repairs. If ‘No’, please advise your intentions regarding repairs or progress to date: 

Are there any other open claims for damage to the property?.......................................................................................................... yes 

 no 

Evidence of repairs supplied: 

Please turn over for Declaration

AMI House Insurance

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Declaration I / we agree that this supplementary application supports my / our insurance application and is required due to the 2010/11 Canterbury Earthquakes and/or 2016 Hanmer Springs Earthquake and their aftershocks. It forms part of the application and policy and I am / we are bound by the same disclosure requirements as any other information provided to AMI Insurance (AMI), a business division of IAG New Zealand Limited. 1.  Material facts All information: (a)  given to AMI (whether verbal or written) is true and correct; (b)  that is relevant to this insurance has been given; otherwise this application may be declined, any resulting policy may be declared void or any claim may be reduced or declined. If any of the information changes, I / we will inform AMI. 2. Collection, Storage and Use of Information All of my / our personal information collected by AMI may be: (a)  used to advise me / us of AMI’s other products or services, (b) used in the administration of insurance of this policy and any other policies I / we have with AMI on which I / we am named or listed, (c) disclosed to other members of the insurance industry and Insurance Claims Register Limited, and to parties who have a financial interest in the subject matter of the policy. AMI is the intended recipient of this information and it may give or obtain information from appropriate individuals or organisations relating to this insurance for underwriting or other insurance purposes. I / we may request access to, and correction of, this information as provided in the Privacy Act 1993. The information will be held by AMI, 1 Fanshawe Street, Auckland 1010. Where I / we provide AMI with personal information about any other person for insurance-related purposes, I / we confirm that I / we have the authority of those persons to disclose such information and to authorise AMI to collect, hold, use and disclose the information for insurance-related and marketing purposes.

On behalf of all applicants

Signature:





Date:   /   /  

Title / position / name:   

Office use only Underwriter’s Name: 

 Date:   /   /  

Terms applied: 

AMI House Insurance

 Date:   /   /  

© Copyright IAG New Zealand Limited 2015. AMI and the AMI logo are registered trademarks of IAG New Zealand Limited.

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AMI0006/8 11/16

Authorised by: 

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