MOTOR WINDSCREEN + GLASS CLAIM FORM...MOTOR WINDSCREEN + GLASS CLAIM FORM 1. INSURED Name: Day...
Transcript of MOTOR WINDSCREEN + GLASS CLAIM FORM...MOTOR WINDSCREEN + GLASS CLAIM FORM 1. INSURED Name: Day...
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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: