GLASS CLAIM FORM
   
INSURED

 
Name:    
Address: Occupation:
Cell: Telephone No:
Fax No: Email Address:
Id No: Vat No:
   
LOSS/DAMAGE OCCURRENCE
Date and time of breakage:
Cause of breakage
Name & address of person
responsible, if applicable
Names & address of Witnesses
   
PREMISES
Address of premises where
breakage occurred
Were premises occupied?: Yes No
By Whom?:
Purpose of occupation:
   
VEHICLE
Model & year
Windscreen tinted or clear?
Drivers name and license details
   
DETAILS OF BROKEN GLASS
Cracked or shattered?
Any signwriting on broken glass?
If insured, provide name of insurer:
   
OTHER INSURANCE
Is there any other insurance
covering the broken glass?
If so, give name of insurer:
   
PAYMENT METHOD
Name of bank:
Branch:
Account Holder:
Branch Code:
Type of account:
Account number:
   
DECLARATION
I/We solemnly declare that the above particulars are true in every respect.
   
Signature: