WINDSCREEN CLAIM FORM

1. Please answer all questions

2. The completion or receipt of this form by the Company, does not mean acceptance of responsibility by the Company

PARTICULARS OF POLICY

Policy No.

Insurance Period (from)

Insurance Period (to)

Vehicle Plate No.

Windscreen Cover Amount

PARTICULARS OF INSURED

Name

Tel

PARTICULARS OF DRIVER

Name

Contact Tel. No.

Address

Birth Date

Identification (ID) / Passport No.

Relation to the Insured

Issue Date of Driving License

Expiration Date

Type of Driving License

Full Learner Professional

ΛΕΠΤΟΜΕΡΕΙΕΣ ΑΤΥΧΗΜΑΤΟΣ

Date

Time

Location

Details of the accident

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 Όχι

ATTACHMENTS (.JPG or .PDF)

Driver’s License

Title

ΜΟΤ

Additional Documents / Photos

ΔΗΛΩΣΗ

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

Signature of Insured

Signature of Driver

WINDSCREEN CLAIM FORM

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WINDSCREEN CLAIM FORM

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LIMASSOL

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