Windscreen Claim - Insurance Broker Melbourne - Consolidated Insurance Agencies

Your Policy Number*
Insured’s Name*
Insured’s Phone*
Email*
Address*
Street Address City State Post Code
Driver’s Name*
Driver’s Age*
Driver’s Licence
Expiry Date
MM slash DD slash YYYY
Make of Vehicle
Model*
Year
Engine Number
Rego
Date of Breakage
MM slash DD slash YYYY
Was the broken windscreen treated? (Please check all that apply)
- Tinted
- Amour Plate
- Zone Toughened
- Banded
- Laminated
Other
Was the windscreen struck by a stone?*
- Yes
- No
If not, state cause*
To ensure you do not incur any unnecessary GST liabilities on this claim please complete the following:
Australian Business Number (ABN) if applicable
Entitlement to input tax credit on respect of the insurance premium? (%)
and the vehicle (%)
On receipt of the account for replacement please pay the repairer direct OR forward cheque to me/us. If the windscreen has already been replaced please attach your account receipt.
Attach File
Max. file size: 2 MB.
If these questions do not cover all the facts of the accident please attach supporting documentation. I declare that the above is a true statement of the facts and all matters relating to this claim.
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