Motor Vehicle Hail Damage Claim

Your Particulars

Vehicle Details

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Details of incident

Were you the driver?

Declaration And Signature of the insured

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.
I confirm: