Windscreen Claim Form WINDSCREEN/GLASS CLAIM FORM Step 1 of 4 25% INSUREDNameFirstLastBusiness/OccupationAddressStreet AddressCityZIP / Postal CodeTelephone:Contact Person: VEHICLE:Make and Model:Registration No. Colour:Type of Body: Year of ConstructionState fully the purpose for which the vehicle was being used at the time of the accident: DRIVER:Name of Driver at the time of accident :FirstLastAge :Please enter a value between 15 and 150.Driver’s Licence Number:Date of Issue: Where Issued: ACCIDENTDate of Breakage: Place Where Breakage occurred: If Insured not present when did he/she receive notification of breakage:Do you intend/is there any likelihood of you trading in your car in the near future?YesNoWhen did you purchase vehicle: When was the Windscreen replaced last? Was there any existing damage prior to this event?YesNoIf so to what extent?Repairer’s Name: FirstLastCost of Replacement:Where can the vehicle be inspected? How was the windscreen broken? CommentsThis field is for validation purposes and should be left unchanged.