MOTOR CLAIM FORM
FOR VEHICLE WINDSCREEN/WINDOW GLASS DAMAGE
Insured Name & Address :
*
Policy/Cover Note No:
Vehicle Particulars
Registration No
Make and Model
Date of Accident
Location of Accident
Brief Description of Accident
Any Third Party Responsible for Loss
Yes
No
If yes, give details
Estimated Loss Amount
Where to be repaired
Any other information relating to this Accident