Windscreen Claim Notification

Name
This field is for validation purposes and should be left unchanged.
General Details
Which branch do you deal with?*
- Maroochydore
- Townsville
- Proserpine
- Mackay
- Ingham
Insured Name*
Contact Name*
Contact Number*
ABN
ITC %
Policy Details
Policy Number*
Unit No
Insurer
Excess
Loss Details
Date of Loss*
Address of Loss*
Time
Insured Vehicle*
Vehicle Location*
Registration Number*
Which glass was damaged?*
Please attach supporting photos/documentation if available
Drop files here or

Max. file size: 128 MB.
Preferred Repairer
Driver Details
Driver Name*
Driver DOB*
Licence Number*
Licence Class*
Licence Expiry Date*
State*
Bank Details
Method
- Cheque
- EFT
Bank Name
BSB
Account Number
Account Name

General Details