Windscreen | Insurance Services

First name

Last name

Phone

Postal Address

Policy # (Leave Blank if Unsure)

Vehicle #

Date and time of loss

Month

Day

Year

Time

HoursMinutes

Location of Loss

Description of Loss (Describe what happened, where and when)

Location of Vehicle (If unable to drive)

Clear Picture Of Your Drivers Licence Card

Stand In Centre - Front Of Car, Picture Of Whole Windshield

Picture Of The Windshield Damage, Close Up

Sit Inside Vehicle, Take A Picture If The Windshield With The Mirror Area

Upload Quote # 1

Upload Quote # 2 (Optional)

Vehicle Registration Sticker Photo

Please upload a clear picture of your vehicle registration certificate or windshield sticker.

ACCF Details

Please upload a clear picture of the vehicle ACCF certificate that would have been issued with you registration certificate

Signature

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Date of Signature

Month

Day

Year