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Motor Glass Claim Form

Complete all sections and submit. Issue of this form is not an admission of liability.

Policy Information

Policy NoCertificate NoClaim NoGroup Scheme Name

1. The Insured

Identity NoFull Name*

Address

Postal CodePhone (Business)Phone (Home)Email

2. The Vehicle

Make*Registration Number*Year of Manufacture

3. Driver at Time of Incident

Full NameIdentity No

Address

Postal CodePhone (Business)Phone (Home)Occupation

4. The Breakage

5. Declaration

I declare that to the best of my knowledge and belief the foregoing particulars are true, correct and a complete disclosure of the circumstances relating to the claim, and I undertake to render to the company every assistance in my power in dealing with the matter. I also declare that there is no other insurance under which a claim can be made and that the said vehicle or other property is my sole property.

Date*

I agree to the above declaration

Issue of this form is not an admission of liability