Glass Claim

Insured

Insured First Name *
Insured Last Name *
Insured Contact *
Insured Contact E-Mail *
Insured Address (line 1)
Insured Address (line 2)
Insured Address (line 3)
Insured Tel (Work)
Insured Tel (Home)
Insured Tel (Cell)
Insured Policy No
Insured Vat No
Exact Type of Aircraft
Aircraft Reg No
Please leave this field empty.

Occurrence

Breakage Date
Breakage Time
Cause of Breakage
Name and Address of Person Responsible For Breakage
Name and Address of Witnesses

Premises

Address Where Breakage Occured
Was Premises Occupied ---YesNo
Premises Occupied by Whom
Purpose of Occupation

Vehicle

Make of Vehicle
Model of Vehicle
Registration Number of Vehicle
Year of Vehicle
Windscreen Type ---ClearShatterproofTintedShatterproofClearArmourPlateTintedArmourPlate
Drivers Full Name
Drivers Licence No
Place of Issue of Licence
Date of Issue of Licence

Broken Glass

Full Detail of Broken Glass
Size in Millimeters
Thickness in Millimeters
Present Condition of Windscreen ---CrackedShattered
Any Signwriting on Broken Glass ---YesNo
Total value of insured Glass (in Rands)
Date of Last Valuation of Glass
Any Other Insurance Covering Glass ---YesNo
If Yes: Supply This Parties Contact Details (Name, Address, Contact Phone)