LIIB Pty Ltd - Glass Claim Form

Glass Claim Form

1INSURED

2OCCURRENCE

3PREMISES

4VEHICLE

5DETAILS OF BROKEN GLASS

6VALUE

7OTHER INSURANCE

8BANKING DETAILS

9DECLARATION

POLICY NUMBER
INSURED
Name and occupation*
Address
Day Telephone Number*
Identity number / Company registration number
VAT number

OCCURRENCE
Date of breakage*
DD slash MM slash YYYY
Time of breakage*

: Hours

Minutes
Cause of breakage*
Name of person responsible for breakage.
Address of person responsible
Names of witnesses
Addresses of witnesses

PREMISES
Address of premises where breakage occurred
Were premises occupied?
By Whom?
Purpose for which occupied

VEHICLE
Vehicle make
Vehicle registration
Model
Year
Windscreen tinted or clear and shatterproof or armour plate?
Driver's name
Drivers licence no
Place of issue
Date of issue
DD slash MM slash YYYY

DETAILS OF BROKEN GLASS
Full description of broken glass
Size and thickness in millimetres
Cracked or shattered?
Any signwriting on broken glass?

VALUE
Total value of all insured glass
When last valued?
DD slash MM slash YYYY

OTHER INSURANCE
Is there any other insurance covering the broken glass? Yes / No
If so, give name of insurer

BANKING DETAILS
NAME OF BANK:
BRANCH AND CODE NO.:
ACCOUNT NO.:
NAME OF ACCOUNT HOLDER:
YOUR SIGNATURE*

DECLARATION
Signature of Insured*
Capacity*
Date
DD slash MM slash YYYY