Windscreen Only Claim Comprehensive Policy Number*From* Date Format: MM slash DD slash YYYY To* Date Format: MM slash DD slash YYYY 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 Date Format: MM slash DD slash YYYY Make of VehicleModel*YearEngine NumberRegoDate of Breakage Date Format: MM slash DD slash YYYY 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 Date Format: MM slash DD slash YYYY CAPTCHAEmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.