Glass Claim Form "*" indicates required fields 1INSURED 2OCCURRENCE3PREMISES4VEHICLE5DETAILS OF BROKEN GLASS6OTHER INSURANCE7DECLARATION POLICY NUMBERINSUREDName and occupation*Day Telephone Number*AddressIdentity number / Company registration numberVAT number OCCURRENCEDate of breakage* Day Month Year Time of breakage* Hours : Minutes AM PM AM/PM Cause of breakage*Name of person responsible for breakage.Address of person responsibleNames of witnessesAddresses of witnesses PREMISESAddress of premises where breakage occurredWere premises occupied?YesNoBy Whom?Purpose for which occupied VEHICLEVehicle makeVehicle registrationModelYearPlease enter a number from 2010 to 2030.Windscreen tinted or clear and shatterproof or armour plate?TintedClearShatterprufArmour PlateDriver's nameDrivers licence noPlace of issueDate of issue Day Month Year DETAILS OF BROKEN GLASSFull description of broken glassSize and thickness in millimetresCracked or shattered?CrackedShatteredAny signwriting on broken glass?YesNoVALUETotal value of insured glass?When last valued? OTHER INSURANCEIs there any other insurance covering the broken glass? Yes / NoYesNoIf so, give name of insurer DECLARATIONI/We solemnly declare that the above particulars are true in every respect. LIIB and applicable service providers can process the applicable personal information for purposes of administrating this claim. Signature of Insured*Capacity*InsuredParentProxySpouseSonDaughterDate Day Month Year
