Motor vehicle Windscreen-only Step 1 of 4 25% Our Preferred Supplier Summary of Benefits Convenient, responsive and highly professional glass replacement service 24 hours / 7 days / 365 days a year. O'Brien is the preferred glass replacement service provider to the majority of Australia's major insurers. O'Brien able to submit claims direct from the client to the insurer or via the broker if desired. National Glass Replacement "No Hassle" Direct Claim Service for Brokers (Excess fee may apply) 158 highly skilled glaziers and 289 windscreen technicians 16 branches, 54 automotive service centres and 92 exclusive dealerships plus an extensive subcontractor network Lodge your claim online by visiting the O'Brien website at www.obrienglass.com.au Steadfast Broker Number: 4182 O'Brien Service offering includes Domestic and commercial glass replacement for the home, shop or office. (shop fronts, doors, counter-tops, partitioning, mirrors, balustrades, curved glass etc) Automotive glass repair and replacement (car, trucks, coaches, vans, and heavy vehicles) Side and rear car windows Windscreen chips repaired Nationwide lifetime guarantee on workmanship All glazing complies with the applicable Australian Standard For Automotive glass replacement (windscreen, side or rear) call O'Brien on 13 16 16. Policy Holder DetailsInsured name or name of policy holder* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*Email* Insured VehicleYear, Make & Model*Vehicle registration* Driver DetailsPlease complete these details in respect of the person in charge of the vehicle at the time of the accident.Full Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Gender*MaleFemaleDate of Birth* DD MM YYYY Accident DetailsDate of accident* DD MM YYYY Time of accident* : HH MM AM PM How it happened* Repair DetailsHave you taken the vehicle to a repairer yet?*YesNoIf yes, please attach a copy of the invoice/quote. Drop files here or DeclarationThe information and answers given above are a true and complete statement of the facts and matters relating to the happening for which this claim is made, and no information likely to affect this claim has been withheld. I authorise my Insurer to undertake on my behalf whatever actions are necessary to indemnify me within the terms of my policy including if necessary, removal of my vehicle to alternative premises to enable repairs to be carried out by a qualified Motor Body Repairer. I understand that this claim may be refused if information is untrue, inaccurate or concealed. I expressly agree that the information given by me is provided with my full knowledge and consent and further agree to hold harmless and indemnify [Value not set] in the event of any action or matter that may be taken by any party pursuant to the Privacy Act 1988 (Cth). I/We acknowledge that I/we have read and understood the paragraphs accompanying this proposal headed “Your Privacy”.Name* First Last Signature* This iframe contains the logic required to handle Ajax powered Gravity Forms.