Glass insurance claim form

Claims number(Required)

Type of insurance(Required)

Policy number(Required)

Name(Required)

First name Insert Surname

Address(Required)

Street + house number City of Postal code

Phone number(Required)

Email address(Required)

Bank account number(Required)

I have checked the above information and modified if necessary.(Required)

Yes

No

What is the date of damage?(Required)

Is there glass breakage to the residential property located at the mailing address?(Required)

Yes

No

Do you own or rent the property?(Required)

Owner

Tenant

Is there single or double glazing?(Required)

Single glass

Double glazing

Do you have an original bill/quote? (You can upload it at the end of this form)(Required)

Yes

No

What is the recovery amount?(Required)

If available, attach the following documents. Photos of the damage. Repair note/quotation.

Drag files here or

Max file size: 30 MB.

Signature(Required)

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