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.; |
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Are You GST Registered?: |
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Policy Period |
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Particulars of Insured Vehicle |
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Was broken windscreen?: |
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Was windscreen struck by stone?: |
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Details of driver of insured vehicle |
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In the last 5 years prior to the inception of this policy, have you |
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Had a motor vehicle stolen?: |
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Lost your licence?: |
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Had any traffic offences, fines or infringements?: |
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Had any prior accidents and/or claims: |
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In the past 10 years, convicted of a criminal offense: |
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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. |
I/We declare that the above is a true statement of the facts and matters relating to this claim.
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).
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.