Claim Form - Motor Vehicle Windscreen - JLT

Motor Vehicle WindscreenClaim FormPLEASE RETURN COMPLETED FORM TO YOUR JLT OFFICE:Jardine Lloyd Thompson Pty LtdGPO Box 1693ADELAIDE SA 5001Tel +61 (0)8 8418 0288Fax +61 (0)8 8223 6903Australian Broking & Risk ServicesPO Box 197Rundle MallADELAIDE SA 5000Tel +61 (0)8 8418 0250Fax +61 (0)8 8359 2877Australian Insurance BrokersPO Box 3290Rundle MallADELAIDE SA 5000Tel +61 (0)8 8418 0260Fax +61 (0)8 8418 0278Jardine Lloyd Thompson Pty LtdPO Box 925ALBURY NSW 2640Tel +61 (0)2 6057 3333Fax +61 (0)2 6057 3399Jardine Lloyd Thompson Pty LtdGPO Box 741BRISBANE QLD 4001Tel +61 (0)7 3246 7555Fax +61 (0)7 3246 7590Jardine Lloyd Thompson Pty LtdPO Box 115CAIRNS QLD 4870Tel +61 (0)7 4031 5299Fax +61 (0)7 4031 5062Jardine Lloyd Thompson Pty Ltd155 Varsity ParadeVARSITY LAKES QLD 4226Tel +61 (0)7 5630 6551Fax +61 (0)7 5630 6531Jardine Lloyd Thompson Pty LtdLevel 17, 607 Bourke StreetMELBOURNE VIC 3000Tel +61 (0)3 9613 1415Fax +61 (0)3 9614 3600Jardine Lloyd Thompson Pty Ltd16 Heddon RoadBROADMEADOW NSW 2292Tel +61 (0)2 4956 1377Fax +61 (0)2 4956 1441Jardine Lloyd Thompson Pty LtdGPO Box E201PERTH WA 6841Tel +61 (0)8 9426 0444Fax +61 (0)8 9426 0999Jardine Lloyd Thompson Pty LtdPO Box H25Australia SquareSYDNEY NSW 1215Tel +61 (0)2 9290 8000Fax +61 (0)2 9299 7280Jardine Lloyd Thompson Pty LtdPO Box 1720TOWNSVILLE QLD 4810Tel +61 (0)7 4722 9000Fax +61 (0)7 4722 9099Jardine Lloyd Thompson Pty LtdGPO Box 724DARWIN NT 0801Tel +61 (0)8 8925 5333Fax +61 (0)8 8925 5399www.jlta.com.au

8. Type of damage: Shattered Bulls Eye Type CrackedVEHICLE DETAILS9. Year of Manufacture Vehicle Make and Model10. Body Type Registration NoDRIVER’S DETAILS11. NameAddressDate of Birth Driver’s licence No ClassesExpiry Date of LicenceYears heldDETAILS OF REPAIR12. Date new windscreen fitted by repairerType of windscreen fitted Laminated Plain Full Tint Banded TintName of repairerAddress13. Has repair account been paid? YES NO Please attached repair accountPlease note:1. Make sure that you give us ALL details about your claim.2. Tell the Police immediately about any loss or damage which has been caused by theft, vandalism or malicious damage to your vehicle.3. Contact your Claims Broker should you require assistance.DECLARATIONI declare that to the best of my knowledge and belief the information in this form is true and correct and I have not withheld any relevantinformation.Signature of insured or person with authorityto sign for or on behalf of the insuredDate:Signature of the driver (if not the insuredDate:* this consent only applies when a claim is submitted in relation to a policy issued to the individual, not a company or business

JLT Collection StatementIn accordance with the Privacy Act 1988 (and subsequent amendments), we, Jardine Lloyd ThompsonPty Ltd (and our subsidiaries and related entities) (JLT) draw your attention to the following:We may collect personal information about you by means of the enclosed document.We are collecting the information principally for the purpose of approaching the (re)insurancemarket, placing insurance, assessing and advising you on your insurance needs, claims handlingor risk management (depending on your requirements). Other purposes include providing youwith information about other JLT products or services and administering payments to you. If youare proposing for or renewing insurance, the information is required pursuant to your duty ofdisclosure under the Insurance Contracts Act 1984, the Marine Insurance Act 1909 or at commonlaw.The information we collect may be disclosed to third parties including but not limited to(re)insurers, insurance intermediaries, service providers, finance providers, advisers, agents andJLT related Group companies.Your personal information may be sent to our administrative processing centre in Mumbai (India)and to other JLT Group companies, insurers, reinsurers and other third party service providers(e.g. data storage providers) in the United Kingdom, Singapore, Hong Kong, the United States ofAmerica and elsewhereIf you provide us with personal information about other individuals, you must ensure that thosepersons have been made aware of the above matters. Where the information collected relates tohealth, criminal record or other sensitive information as defined in the Privacy Act 1988, you mustobtain it with the individual’s consent. We will use and disclose your personal information inaccordance with our Privacy Policy.Our Privacy Policy can be accessed on our website (www.jlta.com.au). For further informationcontact your account executive or the JLT Privacy Officer:Jardine Lloyd Thompson Pty Ltd, 66 Clarence Street, SYDNEY NSW 2000Telephone: (02) 9290 8000D:\Users\actov\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.IE5\NGS7PZ13\Collection Statement under Privacy Act 1988.docx