Motor Vehicle Windscreen Claim Form

I certify that:

I am authorised to submit this claim as:

the insured person,
an authorised representative of the insured person or company, or
a nominated driver on a policy;

I am authorised to provide this information to you for the purpose of making this claim;
The information given in this form is truthful, accurate and complete, and no information likely to affect this claim has been withheld. I understand that this claim may be refused if information is untrue, inaccurate or concealed; and
I/We acknowledge that I/We have read and agree to the privacy consent and authorisation documented at https://insurancespecialists.com.au/privacy-policy

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

Full Name

First Last

Date Signed *

dd/MM/yyyy

When this form is completed and SUBMIT is hit below, a copy of this form will be sent to the email address below (claims@insurancespecialists.com.au) and also to the email address in the Policy Holder section as a Word Document and PDF.

These documents can be sent to both client and insurer.

Important Notices *

Duty of Disclosure

In accordance with the provisions of the Insurance Contracts Act 1984 (Cth), you and everyone who is an insured under your policy and/or everyone who arranges insurance on behalf of a business entity and/or body corporate, must comply with the Duty of Disclosure.You must disclose anything that you know, or could reasonably be expected to know, that may affect the Insurer's 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 Business Insurance Specialists Pty Ltd (BIS).

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.

Privacy

BIS has always valued the privacy of personal information. If you would like a copy of our Privacy Policy, you can contact us or access it from our website at www.insurancespecialists.com.au/privacy-policy.

Complaints

Contact us and tell us about your complaint. We will do our best to resolve it quickly.

If your complaint is not satisfactorily resolved within 10 working days, please contact Business Insurance Specialists Pty Ltd on (07) 3139 3900 or put your complaint in writing and send it to GPO Box 2217, Brisbane QLD 4001 at the address noted at the beginning of this FSG. We will try and resolve your complaint quickly and fairly.

Business Insurance Specialists Pty Ltd is a member of the Australian Financial Complaints Authority (AFCA). If your complaint cannot be resolved to your satisfaction by us, you have the right to refer the matter to the AFCA. AFCA provides fair and independent financial services complaint resolution that is free to customers.

The AFCA can be contacted at:

Company: Australian Financial Complaints Authority

Postal: GPO Box 3, Melbourne, VIC 3001

Phone: 1800 931 678

Email: info@afca.org.au

Website: www.afca.org.au

I have read the Important Notices.

	Yes	No
If driver has received any infringement notices, licence suspensions or cancellations in the past 5 years *
If driver/insured has had any criminal convictions in the past 5 years. *

Motor Vehicle Windscreen Claim Form

Insured's Details

Claim Details

Declaration

Error Occurred

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Form Summary

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