TOWER Insurance - Papua New Guinea

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	Windscreen Damage	Claim No.
TOWER	Claim Form	Date of Loss.
Insurance

PLEASE ANSWER ALL QUESTIONS IN FULL. ANY DELAY IN RETURNING THIS FORM MAY PREJUDICE YOUR CLAIM UNDER THIS POLICY

INSURED NAME :		PHONE :
INSURED ADDRESS :		FAX :
NAME OF DRIVER :
LICENCE NO : TYPE :		DATE OF EXPIRY :

POLICY NO:	CLIENT REFERENCE NO :	DUE DATE :
VEHICLE:	BODY TYPE :	REGISTRATION NO :
DATE OF LOSS :	TIME :
LOCATION & DETAILS OF LOSS :

REPAIRER :
ADDRESS :
COST OF REPAIRS : K	(NB SUPPORTING QUOTATIONS TO BE ATTACHED)

TOWER INSURANCE IS HEREBY AUTHORISED TO FINALISE
MY/OUR CLAIM BY PAYMENT OF THE COST OF REPAIRS TO :

PAYEE :

THIS CLAIM FORM IS TO BE USED FOR BROKEN WINDSCREEN AND/OR WINDOW GLASS ONLY. IF THERE IS ANY OTHER DAMAGE OR IF PERSONAL INJURIES HAVE BEEN SUSTAINED, THE COMPANY'S MOTOR VEHICLE CLAIM FORM MUST BE USED.

SIGNATURE OF CLAIMANT :

DATE :