MOTOR WINDSCREEN + GLASS CLAIM FORM
1. INSURED
Name: Day contact no: Occupation:
Address:
2. OCCURRENCE
Date of breakage: Time of breakage: Cause of breakage:
Name + address of person responsible for breakage:
Name + address of witness:
3. PREMISES
Address of premises where breakage occurred:
Were premises occupied? By whom?
Purpose for which occupied?
4. VEHICLE
If vehicle is subject to Hire Purchase, Credit or Leasing
Agreement, state name and address of Finance Company:
Make: Model + year: Reg no:
Windscreen tinted or clear? Windscreen shatterproof or armour
plate?
Driver’s name: License no:
Place: Date of issue:
5. DETAILS OF BROKEN GLASS
Description of broken glass:
Size + thickness in mm: Cracked or shattered: Any signwriting on
broken glass?
BROKER: POLICY NO:
INSURER: CLAIM NO:
VAT REG NO:
6. DECLARATION
I / We solemnly declare that the above particulars are true and
complete in every respect.
Name: Capacity: Date:
Signature:
Dougall Insurance Brokers (Pty) Ltd t/a Crawford Dougall
Insurance Brokers130 Adelaide Tambo Drive Durban North 4051 • PO
Box 47593 Greyville Kwazulu-Natal South Africa 4023
Tel: +27 31 207 3272 • Fax: +27 31 207 8256 • Email:
[email protected]: AC Dougall (Managing), SC Dougall, WM
Sutherland
Reg. No. 2005/018355/07 FSB Licence No. 24450
BROKER: POLICY NO: INSURER: CLAIM NO: VAT REG NO: Name: Day
contact no: Occupation: Address: Date of breakage: Time of
breakage: Cause of breakage: Name address of person responsible for
breakage: Name address of witness: Address of premises where
breakage occurred: Were premises occupied: By whom: Purpose for
which occupied: If vehicle is subject to Hire Purchase Credit or
Leasing Agreement state name and address of Finance Company: Make:
Model year: Reg no: Windscreen tinted or clear: Windscreen
shatterproof or armour plate: Drivers name: License no: Place: Date
of issue: Description of broken glass: Size thickness in mm:
Cracked or shattered: Name_2: Capacity: Date:
