Windscreen Claim Form

  • Client Details

  • Goods & Services Tax (GST)

  • To ensure you do not incur any unnecessary GST liabilities on this claim please advise your

  • Entitlement to an Input Tax Credit in respect of the

  • Particulars of Insured Vehicle

    (tick as appropriate)
  • Electronic Funds Transfer Details

  • Following insurers approval of your claim, should you wish to have your funds transferred directly into your bank account, please provide the following details.

  • Declaration

  • The information is, to the very best of my knowledge, true in every respect.