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Your duty of disclosure

Before you enter an insurance contract, you have a duty of disclosure under the Insurance Contracts Act 1984. If we ask you questions that are relevant to our decision whether to insure you and on what terms, you must tell us anything that you know and that a reasonable person in the circumstances would include in answering the questions. You have this duty until we agree to insure you.

If you do not tell us something

If you do not tell us anything you are required to tell us, we may cancel your contract or reduce the amount we will pay you if you make a claim, or both. If your failure to tell us is fraudulent, we may refuse to pay a claim and treat the contract as if it never existed.

By proceeding you confirm you have read and understood this duty

    Page 1. Insured Details

    Insured Name


    Phone No.

    Your Email

    Policy Number

    GST Section

    Are you registered for GST purposes?


    Are you entitled to claim GST on replacement of your windscreen?

    Please advise

    Page 2. Driver Details



    Date Of Birth

    License No.

    Licence Expiry Date

    Years Licenced

    List any restrictions on the licence:

    Did the driver drink any alcohol, or take any drugs or medication 12 hours prior to the accident?

    Please state the details

    What did the driver drink or what drugs did the driver take?

    Has the driver within the past 5 years been convicted of motoring offences (other than
    parking) or disqualified from driving?

    Please state the details

    Page 3. Vehicle Details





    Page 4. Accident Details

    Date of Incident

    Time of Incident

    Address of Incident

    Please Select Damaged Area

    Repairer Details

    Name of Repairer


    Upload Invoice or Quote

    Page 5. Payment Details

    To assist with prompt reimbursement, please provide your bank details

    Account Name


    Account Number


    I/ We declare that the best of my/our knowledge and belief the information in this form is true and correct and I/we have not withheld any relevant information.

    I/we consent to the insurance company using my personal information I/we have provided on this form for the purpose of processing my claim. I/we understand that if I/we choose not to provide required details, this is my/our choice, however the insurance company may not be able to process my claim.

    I/we consent to the insurance company disclosing my personal information to other insurers, an insurance reference services or as required by law. I/we consent to the insurance company also disclosing my personal information about me, from investigators or legal advisors.

    Please add your Digital Signature here


    Print Name

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