Home Shop & Office Online Insurance Claim Form

To complete the booking process we require some additional information from you. Please complete the details below and submit.

Between the hours of 07.00 hrs and 24.00 hrs one of our consultants will contact you within 60 minutes by phone to finalise your appointment request. Outside of these hours you will be contacted by 09.00 hrs the next day. Please endeavour to supply a number that we will be able to contact you on within the next hour e.g. a mobile telephone if you have one or your work number if you are at work. All fields marked with an asterisk (*) are mandatory.

Title
First name*
Surname*
Street number*
Street address*
State*
Daytime telephone number*
Evening telephone number*
Mobile number (if applicable)
Email address*
Authorisation number (to be completed by O'Brien^®)
Insurance company*
Broker
Claim number (if known)
Policy number
Excess
Commercial business glass claim: Goods & Services Tax - to ensure you do not incur any unnecessary GST liabilities on this claim please advise your Australian Business Number (ABN) if applicable
Location of broken glass
Date of damage (dd/mm/yy)
How did the glass breakage occur?
Please provide the name and address of the person responsible for the breakage (if known)
Did the police attend? (if applicable)
State the name of the police officer
Do you know which police station the officer was stationed at? (please state)
Date (dd/mm/yy)
Time (including AM or PM)
Police Report Number
Privacy policy and legal notices	The personal information you give us will be used by O'Brien^® to provide the service you have requested and as set out in our privacy policy. We may use it to send you marketing messages (by mail, email and telephone) about related services which may be of interest to you. If you do NOT wish to be sent marketing messages please tick the box: By clicking 'Submit' you confirm that you have read and agree to the terms of our privacy policy and our legal notices. Unless you have ticked the appropriate box above to decline, by clicking 'Submit' you are also consenting to receive marketing messages (by mail, email and telephone) about related services which may be of interest to you.

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For a quick and easy way to make an appointment book online now.

Contact us

Call us on 1800 633 721

You can also contact us via email.