Windscreen Claim Notification

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1. Policy holder information

Policy holder name

What is your policy number?*

Are you a Business or an Individual?*

BusinessIndividual

Business Name (optional)

First name*

Surname*

Policy holder address

Street Number

Street Name

Street Type - Select - Avenue Boulevard Circuit Close Corner Court Crescent Drive Gardens Heights Highway Parade Parkway Road Street Way ---------- Alley Approach Arcade Brow Bypass Causeway Circus Copse Cove End Esplanade Flat Freeway Frontage Glade Glen Green Grove Lane Link Loop Mall Mews Packet Park Place Promenade Reserve Ridge Rise Row Square Strip Tarn Terrace Thoroughfare Track Trunkway View Vista Walk Walkway Yard

Suburb*

Postcode*

State / Territory - Select - NSW ACT VIC QLD NT SA WA TAS

Your Contact Details

Are you the policy holder?*

Yes No

First name*

Surname*

Mobile

Home Phone

Work Phone

Email*

Your preferred method of contact*

MobilePhoneEmail

Best time of day to contact you

AMPM

Nominate a representative to speak on your behalf

2. Claims details

Incident Information

Car registration number*

Date the incident occurred

Tell us in detail what happened*

Is the damage to the front windscreen in the driver's line of vision?*

Yes No

What is the size of the damage?* - Select - Small chip (smaller than 20 cent piece) Large chip (greater than 20 cent piece) Small crack (diameter smaller than 20 cent piece) Large crack (diameter greater than 20 cent piece) Whole glass panel