Windscreen Claim Form Company Name * Occupation * Postal Address * Residential Address * Policy Number * Date Premium Paid * To Whom Paid * Telephone No. * Type * CC * Make * Registration No. * Year of Manufacture * Sum Insured * Purpose for which it is /was being used at Time of Accident Name of Driver * Address * Date of Issue * Age * Driving Licence No. * Group covered * How long has (s)he been driving motor vehicle? * Has (s)he been concerned in any previous accidents. * Yes No If your answer is yes, give details Does he or she have any physical defects * Yes No Since when has he or she been so employed by you? * Give full details of all driving convictions and endorsements of licence (if no conviction state “none” None * None Is (s)he is your direct employee? * Yes No If your answer is yes, in what capacity? * Date of Damage * Exact Time * Place * Speed of vehicle * State weather and light at Time of Accident * Type of Road Surface * Explain briefly how the Breakage happened State extent of damage * Have any instruction been given for repairs to be put in hand? * Where can the vehicle be inspected? * Estimated Cost of Repairs * Was the Glass or surround damaged or weakened in any way before this incident * Yes No
