Glass Claim Form

form, fill out in print and fax to : 0865 202 355

No 2 The Colosseum Building
Century City  Boulevard

 Century City

PO Box 90 Century City 7446
Tel: (27) (21) 529 7800 
Fax: 0865 202 355
E-mail: insure@aib.co.za
 Insured
Name
 
Surname  
Address  
Telephone  
Fax  
E-mail  
Policy Number  
VAT Registration Number  
 Damage Occurance
Date and time of breakage  
Cause of breakage  
Name and address of person responsible for breakage  
Names and addresses of witnesses :  
   
   
   
 Premises
 Fill in this section if damaged glass was port of or on the premises.
Address of premises where breakage occurred  
Were premises occupied?  
If yes, by whom?  
Purpose for which occupied  
 Vehicle
 Fill in this section if damaged glass was part of a vehicle.
Vehicle make  
Registration Number  
Model and year  
Windscreen : (Circle relevant answer/s)  Clear     Tinted     Shatterproof     Armour plate
Driver's Name  
Driver's Licence Number  
Place of issue  
Date of issue  
 Details of broken glass
Full description of broken glass:  
   
   
   
Dimensions of glass (in millimeters) Width                mm  :  Height                mm
Thickness of glass (in millimeters)                  mm
Cracked or shattered : (Circle relevant answer/s)      Cracked     Shattered
Any sign writing on broken glass : (Circle relevant answer/s) Yes     No
 Value
Total value of insured glass  
When was the glass last valued?  
 Other Insurance
Is there any other insurance covering the broken glass? : (Circle relevant answer/s) Yes     No
If yes, give name of insurer  
 Authority for payment
It is recommended that any amount payable to you directly be transmitted by Electronic Bank Transfer for speedier settlement and security reasons.
Do you agree to this? : (Circle relevant answer/s) Yes     No
 Signature
Name  
Signature  
Please print the completed form and fax the signed document to 0865 202 355