Plate Glass Claim – Westwood Insurance Brokers

Plate glass damage claim

Insured

Policy Number *

Identity Number / Registration Number *

Contact Number *

Description of Breakage

Address Where Breakage Occurred *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date of Breakage *

Size of Broken Glass *

Description of Broken Glass *

Position of Broken Glass *

Eg. House, Shop Door, Fanlight, Showcase

Cause of Breakage *

Is The Person Responsible For Glass Breakage Identifiable *

First Choice
Second Choice

Name of Person Responsible for Glass Breakage

First

Last

Address of Person Who Broke The Glass

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Are There Any Witness 1 *

First Choice
Second Choice

Name of Witness 1 *

First

Last

Contact Number *

Name of Witness 2 *

First

Last

Contact Number

Please Attach Pictures of Broken Glass *

Click or drag files to this area to upload. You can upload up to 3 files.

By Submitting This Form I Agree That The Foregoing Particulars To Be True And Correct And Undertake To Render Every Assistance In My Power In Dealing With This Matter *

I Agree

Signature

Clear Signature

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Westwood Insurance Brokers (Pty) Ltd is an authorised financial services provider | FSP No.: 16726