Windscreen Claim Form - Action Insurance Brokers

1. Policyholder

Full Name of Policyholder(*)

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Address(*)

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Claim Contact Name (if different to policy holder)(*)

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Mobile:(*)

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Email address(*)

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Insurer(*)

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Policy Number(*)

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Expiry Date(*)

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GST Details: Are you registered for GST Purposes?(*)

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ABN(*)

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Have you claimed an input tax credit on GST against this policy?(*)

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To what extent are you entitled to claim an Input Tax Credit for this policy? (%)(*)

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2. Insured Vehicle

Make(*)

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Model(*)

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Year of Manufacture(*)

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Registration No(*)

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Engine No(*)

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V.I.N.(*)

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Has the Windscreen been repaired(*)

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Repair Invoice and Receipt upload

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3. Driver (Please complete these details in respect of the person in charge of the vehicle at the time of the Incident)

Full Name of Driver(*)

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Date of Birth(*)

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Mobile(*)

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Drivers Licence No(*)

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Class of Licence(*)

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Expiry Date of Licence(*)

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4. Incident

Date of Incident(*)

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Time of Incident (am/pm)(*)

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Name of street where Incident occurred(*)

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Suburb(*)

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Postcode(*)

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State clearly and fully how the Incident occurred (space for 1000 words) (*)

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Declaration

The information and answers given above are a true and complete statement of the facts and matters relating to the happening for which this claim is made, and no information likely to affect this claim has been withheld.

I/We agree with the above statement(*)

Yes

No

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Anti-Spam(*)

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