Glass Claim Form "*" indicates required fields 1INSURED 2OCCURRENCE3PREMISES4VEHICLE5DETAILS OF BROKEN GLASS6OTHER INSURANCE7DECLARATION POLICY NUMBERYour Email Address Please enter your email if you would like a copy.INSUREDName and occupation*Address and Day Telephone NumberIdentity number and VAT number OCCURRENCEDate and time of breakageCause of breakage*Name and address of person Responsible for breakage.Names and addresses of witnesses PREMISESAddress of premises where breakage occurredWere premises occupied? By Whom?Purpose for which occupied VEHICLEVehicle make and registrationModel and yearWindscreen tinted or clear and Shatterpruf or armour plate?Driver's name and licence no. / Place and date of issue DETAILS OF BROKEN GLASSFull description of broken glassSize and thickness in millimetresCracked or shattered?Any signwriting on broken glass?VALUETotal 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.Signature of Insured*Capacity*InsuredParentProxySpouseSonDaughterDate DD dash MM dash YYYY
