Windscreen Only Claim Comprehensive Policy Number*From* To* Insured’s Name*Email* Insured’s Age*Address* Street Address City State / Province / Region ZIP / Postal Code Insured’s Phone*Insured’s Email* Driver’s Name*Driver’s Age*Driver’s LicenceExpiry Date Make of VehicleModel*YearEngine NumberRegoDate of Breakage Was the broken windscreen treated? (Please check all that apply) Tinted Amour Plate Zone Toughened Banded Laminated OtherWas the windscreen struck by a stone?*YesNoIf 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 applicableEntitlement 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. 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. Please type your name below to agree to our termsDate CAPTCHAEmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.