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Glass Claim Form

NB: This claim form is to be used for a broken Windscreen/Glass Only claim event. Where there is any other damage, or the event relates to a theft or attempted theft/break-in event, the One Underwriting General Motor Claim Form must be completed.

Are You GST Registered?:

Policy Period

Particulars of Insured Vehicle:

Was broken windscreen?:




Was windscreen struck by stone?:

NB: If these questions do not cover facts of incident please attach a general description.

Basis of settlement: O’Brien Glass is our nationally appointed provider for Windscreen/Glass repair and replacement. You can contact O’Briens on 13 16 16 to arrange a time suitable for repair or replacement. For replacement by any other method, a Quotation should be obtained and provided with this Claim Form for our assessment and approval, payment will be made by reimbursement only.

Declaration

I/We declare that the above is a true statement of the facts and matters relating to this claim.

Your Duty of Disclosure:

Before you enter into a contract of insurance, you have a duty under the Insurance Contracts Act 1984 (Clth)to disclose anything that you know, or could reasonably be expected to know, that may affect our decision to insure you and on what terms. This includes your driving record and insurance history for the previous five (5) years and any criminal convictions whether current or spent for the previous ten (10) years prior to the inception of, or renewal of the insurance Policy.

You have that duty after proposal, and up until the time we agree to insure you. You have the same duty before you renew, extend, vary or reinstate a contract of insurance.

You do not need to tell us anything that:

  • reduces the risk that is insured;
  • is common knowledge;
  • Your insurer knows or should know as an insurer; or
  • the insurer waives compliance with your duty of disclosure.

If you are uncertain about whether or not a particular matter should be disclosed to the insurer, please contact Us or your appointed insurance broker.

Non Disclosure:

If you do not tell your insurer anything you are required to, the insurer may cancel your contract or reduce the amount that is required to pay you if you make a claim, or both. If your failure to disclose is fraudulent, the insurer may refuse to pay a claim and treat the contract as if it never existed.

Short Form Privacy Disclosure and Consent

  1. One Underwriting Pty Ltd is committed to protecting your personal information in accordance with the Australian Privacy Principles under the Privacy Act 1988 (Cth). We collect, use and disclose personal information to offer, promote, provide, manage and administer our various insurance services we are involved in as set out in the One Underwriting Privacy Notice. In order to do this, we may also share your information with other persons or entities who assist us in providing or promoting our services as set out in the One Underwriting Privacy Notice. Further information about our privacy practices can be located in the One Underwriting Privacy Policy, a copy of which can also be sent to you on request by your One Underwriting representative. You may also gain access to your personal information, or modify your privacy preferences, by contacting your One Underwriting representative or our Privacy Officer through the means set out in the One Underwriting Privacy Notice.
  2. If you are disclosing personal or sensitive information about any other person to One Underwriting, you confirm that you have obtained the consent of that person to disclose to One Underwriting their personal or sensitive information and you have made them aware that One Underwriting will or may disclose their information to third parties that are reasonably necessary to assist in the provision of the relevant services or products. If you have not obtained consent from this other person to disclose their personal or sensitive information to One Underwriting, you will inform us before providing the relevant information to us.

By submitting this Quotation & Proposal Securus Motor Insurance, you acknowledge that you have read the One Underwriting Privacy Notice and agree that we can handle any personal information you have provided to us in the manner set out above Unless you tick here, we or any of our group of companies may be in touch by any means (including email or SMS) at any time to let you know about goods, services or promotions that may be of interest to you.

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