GLASS CLAIM FORM  
 
Date* :
 
Insurance Company* :
 
Address* :
 
Postcode* :
   
Phone :
 
Claim Number* :
 
Policy Number* :
 
Expiry Date* :
CLIENTS DETAILS  
 
Name of insured (As on policy)* :
 
Address :
 
Postcode* :
 
Email Address* :
   
Phone (Home) :
   
Phone (Work) :
 
Address of breakage* :
 
Postcode* :
 
How did the breakage occur* :
   
If the damage was malicious were police notified
   
Event Number :
   
Date Reported :
   
Police Station :
 
Date of Breakage:
   
How many panels are broken :
 
Type & Thickness of glass:
 
Type of frame:
 
Description of breakage:
 

 


 
1300 EVERCLEAR

Everclear Glass and Glazing Pty ltd
27 Walker Street South Windsor NSW 2765

Email us

Email: [email protected]

 
 
 
 
 
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