Glass Claim Form
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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?:

Details of driver of insured vehicle
Today
In the last 5 years prior to the inception of this policy, have you
Had a motor vehicle stolen?:

Lost your licence?:

Had any traffic offences, fines or infringements?:

Had any prior accidents and/or claims:

In the past 10 years, convicted of a criminal offense:

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

Basis of settlement: We can assist with repair or replacement of your damaged glass through one of our nationally accredited repairers on submission of this form. 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 to take Reasonable Care not to Misrepresent

You have a duty to take reasonable care not to make any misrepresentation when entering into, varying, extending or renewing the Policy.

This means that it is essential that You respond to specific questions that We ask honestly and to the best of Your knowledge, including where We ask You to confirm or update information that You have previously given to Us when entering into, varying, extending or renewing the Policy.

For example this will include You or any other persons to be covered under this Policy and their driving record, claims (or incidents unclaimed or uninsured for), criminal and insurance history. This duty also extends to, but not limited to how Your Vehicle is Garaged, registered or used in frequency and nature of use for example Private Use, Business Use or otherwise.

To assist You with providing Us with honest and accurate responses to any questions We ask of You, We have endeavored to ensure that any question We ask are clear and easy to understand. Further, where possible, We have also included examples of the types of responses We are looking for when asking a particular question. If You are unclear of any particular question or would like Us to explain it to You, please get in touch with Us and We will explain this to You.

In determining whether You have fulfilled this duty to take reasonable care not to make a misrepresentation to Us, We will consider all of the relevant circumstances of a particular case. If You do not respond honestly and accurately to specific questions that We ask, We may (acting reasonably) cancel Your contract or reduce the amount We will pay You if You make a claim, or both. It is therefore vital that You be honest and specific in Your responses. If Your failure to tell Us is fraudulent, We will refuse to pay a claim and treat the Policy as if it never existed (this does not mean that We will refund any premiums that You have already paid).

 

 

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 Claim form, 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 and you agree for One Underwriting Pty Ltd or Aon to send me information about its goods, services and promotions via email or phone.