GLASS CLAIM FORM - Genesis Insurance Brokers

JHB: 011 789 7845
PE: 087 701 2222
info@genesisib.co.za
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Funds Protect

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Homeowners Insurance

Household Contents

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Personal Liability

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Watercraft Insurance

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Accidental Damage

Accounts Receivable

Buildings Combined

Business All-risks

Business Interruption

Defective Workmanship

Electronic Equipment

Employers Liability

Fidelity Guarantee

Fire Insurance

Funds Protect

Glass Insurance

Goods in Transit

Group Personal Accident

Money Insurance

Motor Insurance

Motor Traders

Office Contents

Products Liability

Public Liability

Theft Insurance

Specialist Insurance

Agricultural Insurance

Aviation Insurance

Body Corporates

Commercial Crime

Contractors All-Risk

Cyber Liability

Directors Liability

Environmental Liability

Erection All-Risks

Events Liability

Fine Arts and Collectibles

Guarantees

Heavy Commercial Vehicles

Hospitality Insurance

Kidnap and Ransom

Marine Insurance

Medical Equipment Insurance

Medical Malpractice

Plant All-Risks

Prize Indemnity

Professional Indemnity

Security Liability

Travel Insurance

Wedding Insurance

Agricultural Insurance

Aviation Insurance

Body Corporates

Commercial Crime

Contractors All-Risk

Cyber Liability

Directors Liability

Environmental Liability

Erection All-Risks

Events Liability

Fine Arts and Collectibles

Guarantees

Heavy Commercial Vehicles

Hospitality Insurance

Kidnap and Ransom

Marine Insurance

Medical Equipment Insurance

Medical Malpractice

Plant All-Risks

Prize Indemnity

Professional Indemnity

Security Liability

Travel Insurance

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GLASS CLAIM FORM

Step 1 of 9

11%

BROKER/AGENT(Required)

POLICY NUMBER(Required)

VAT REG NUMBER(Required)

INSURED

Name and occupation(Required)

Address and day phone number(Required)

OCCURRENCE

Date and time of loss/damage(Required)

DD slash MM slash YYYY

When was the loss/damage discovered?(Required)

PREMISES

Address of premises where breakage occurred

Were premises occupied?

Yes

No

By whom?

Purpose for which occupied

OCCURRENCE

Cause of breakage

Name and address of person responsible for breakage

Name and address of witness

VEHICLE

Vehicle make and registration number

Model and year

Windscreen tinted or clear and shatterproof or armour plate

Driver’s name and licence number

Place and date of issue

DD slash MM slash YYYY

DETAILS OF BROKEN GLASS

Full description of broken glass

Size and thickness in millimetres

Cracked or shattered

Cracked

Shattered

Any signwriting on broken glass

Yes

No

VALUE

Total value of all insured glass

When last valued?

OTHER INSURANCE

Is there any other insurance covering the broken glass

Yes

No

Please give the name of the insurer

DECLARATION

I/We warrant that the answers given are true and correct. All details provided on this form are done so honestly and in good faith. This means that The Insurer has been made aware of all important information and that any incorrect information may mean that the claim may be rejected and the policy cancelled.

Insured’s Signature

Insured’s Signature

Capacity

Capacity

Date

DD slash MM slash YYYY

Date

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Johannesburg Office:

+27 11 789 7845

41 Waterford Office Park, Waterford Drive, Fourways, 2055

+27 11 789 7845
41 Waterford Office Park, Waterford Drive, Fourways, 2055

Cape Town
Office:

Cape Town Office:

+27 21 556 8371

5 Frere Ave, Table View, Cape Town, 7441

+27 21 556 8371
5 Frere Ave, Table View, Cape Town, 7441

Port Elizabeth Office:

+27 87 701 2222

49 Worraker Street, Newton Park, Port Elizabeth, 6001

+27 87 701 2222
49 Worraker Street, Newton Park, Port Elizabeth, 6001

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Big Enough To Make A Difference

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JHB: 011 789 7845
PE: 087 701 2222
info@genesisib.co.za
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