Windscreen Claim Form

Your Name/ Company Name

ID Number/ Company Reg Number

Email Address

Contact Number

The date the windscreen was damaged

Vehicle Registration Number

By completing and submitting this form electronically you warrant to the following:

I have suffered a loss to the property described or uploaded via this website.

The information that I have provided is true.

If any part of this claim, or the information provided, is false or fraudulent that I will not be entitled to any benefits.

If I have deliberately caused the loss that I will not be entitled to any benefits.

Your Name

In what capacity are you signing?

Date

I confirm:

that this form has been completed electronically and all information submitted is true and accurate

Captcha

If you are human, leave this field blank.

Windscreen