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Windscreen Claim Form

Completed By*

Client Code

Insured Name*

Was the driver the insured?*

Yes

No

Have you been licensed since 18?*

Yes

No

Type of License*

Incident Date*

Incident Time*

Incident Location*

Incident Description*

Your Vehicle

Year*

Make, Model*

Rego*

Are you happy to use O'Brien*

Yes

No

If no, your insurer will usually reimburse you for the repair costs after you've paid for them

Are you registered for GST?*

Yes

No

Any additional notes/concerns

Upload Photo (optional)

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PO Box 349, KYNETON VIC 3444

20 High Street, KYNETON VIC 3444

hello@macedonrangesinsurance.com.au

03 4411 2704

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Macedon Ranges Insurance Pty Ltd | ABN 65 672 507 191 | Authorised Representative of Ausure Pty Ltd ABN 94 096 971 854 AFS License No 238433

Disclaimer: The information provided on this website is for general information purposes only, and it is not a substitute for professional advice. You should always consider the PDS/Policy wording before making a decision. Coverage may differ based on specific clauses in individual policies. Refer to the FSG on our website or by requesting a copy for our services and remuneration details.

Macedon Ranges Insurance is a member of NIBA and endorse the Insurance Brokers Code of Conduct which can be found here.

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