MOTOR VEHICLE HAIL DAMAGE CLAIM FORM

Broker Name and Branch:




Occupation or Type of Business:

Your Email



Vehicle Details

Year, Make and Model:

Registration Number:



Damage

Please state how the damage occurred:

Date and Time of damage:

Declaration and Signature


We the undersigned, declare the aforegoing particulars to be true in every respect. We understand that we will not be entitled to any benefits or indemnification of this claim, if the claim submitted is fraudulent in any manner whatsoever, whether submitted by ourselves or any of our agents.

Name of Driver:

Date:

Name of Insured:

Date:

Send me a copy of this claim:

Yes

Click to confirm: