Submitted by mindq on Thu, 11/07/2019 - 08:03 * Indicates required field Insured Full Name Postal Address Contact No Occurrence Date and time of breakage Date and time of breakage: Date Date and time of breakage: Time Cause of Breakage Name and address of person responsible for breakage Name and address of witness Are you claiming a windscreen or glass on your building? Windscreen Glass on building Building glass Address of premises/building where breakage occured Who occupies the premises? Purpose for which occupied Any sign writing on the broken glass? Yes No Vehicle Windscreen Make Model Year Registration No Is windscreen tinted or clear? Tinted Clear Is the glass cracked or shattered? Cracked Shattered Full description of the incident Vehicle Chassis number Affected screens Front Screen Back Screen Side Glass Door Glass Is there other insurance covering the broken glass? Yes No Name of Insurer Declaration I / We solemnly declare that the above particulars are true in every aspect agree CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. What code is in the image? Enter the characters shown in the image. Get new captcha!
