Policy No*
Insured*
Address*
Vehicle Reg. No*
Make of Vehicle
Type of Vehicle*
Name of Driver
Date of Incident.*
Date Format: MM slash DD slash YYYY
Description of Incident and Damage.
Name of Garage.
Cost of Replacement
Has any damage been caused to the vehicle other than the breakage of the Windscreen / windows
Post Image
Consent*
l / We hereby certify that the above answers are true to the best of my/our knowledge and belief.

IMPORTANT NOTE:
The cover afforded under the Windscreen extension endorsement has come to an end as a result of this claim. The
cover can be reinstated on payment of the appropriate premium. If you require the cover to be reinstated simply write to
us giving us your instructions and enclosing your remittance.

Windscreen Damage Claim Form.