WINDSCREEN CLAIM FORM
Motor vehicle insurance
POLICY HOLDER INFORMATION
Name
*
First Name
Last Name
Address
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
I would you like to direct this request to a particular OVIB broker
Broker's name
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VEHICLE & DRIVER INFORMATION
Vehicle information
*
Year, make & model
Vehicle registration
*
Driver name
*
Driver contact details
If different to your contact details above
Driver date of birth
*
-
Day
-
Month
Year
Licence Number
*
Licence state of issue
*
Please Select
VIC
NSW
QLD
TAS
SA
WA
NT
ACT
Licence expiry
*
-
Day
-
Month
Year
Licence class
*
Please Select
Full driver licence
Heavy vehicle licence
Probationary licence
Learner permit
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INCIDENT DETAILS
Date of damage
*
-
Day
-
Month
Year
Approximate time of damage
*
Minutes
AM
PM
AM/PM Option
What happened?
*
Address where damage occurred
*
E.g. Great Alpine Rd OVENS
Was the vehicle parked at the time of damage?
*
Please Select
Yes
No
Is the vehicle drivable?
*
Please Select
Yes
No
Has the windscreen been repaired/replaced?
*
Please Select
Yes
No
If yes, please attach a copy of the paid invoice for reimbursement
If yes, name of repairer
File Upload
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Choose a file
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SETTLEMENT DETAILS
Account name
BSB
Account Number
Are you registered for GST?
*
Yes
No
ABN
Please verify that you are human
*
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