WINDSCREEN CLAIM FORM

PARTICULARS OF POLICY

Policy Nr

Insurance Period (from)

Insurance Period (to)

Vehicle Plate Nr

Windscreen Cover Amount

PARTICULARS OF INSURED

Name

Tel

PARTICULARS OF DRIVER

Name

Contact Tel. Nr

Address

Date of Birth

ID Card/Passport Nr

Relation to the Insured

Issue Date of Driving License

Expire Date

Type of Driving License

Full Learner Professional

DETAILS OF ACCIDENT

Date

Time

Location

Details of Acciden

What was the purpose of the use of vehicle during the accident?

The driver drove with the consent of the insured?

yes no

Do you have submitted other windscreen claims during the last insurance period under the same insurance contract?

yes no

ATTACHEMENTS (.JPG or PDF)

Driver’s License

Title

MOT

Additional Documents / Photos

DECLARATION

I declare that the above are true and no material information has been concealed, altered or presented inaccurately.

Signature of Insured

Signature of Driver