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

Make of Vehicle

Model*

Year

Engine Number

Rego

Date of Breakage

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

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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