CORPORATE HEADQUARTERS. Capitol Hill Towers, 6th Floor, Cathedral Road, Nairobi.
P O BOX. 34530 - 00100 Nairobi TEL. 20 2728603/4, 20 2961000, 20 2962000 FAX. 2728605
EMAIL. [email protected] WEB. www.korient.co.ke
Windscreen / Window Glass Claim Form
IMPORTANT NOTICE |
1 Please note that we will require the Original ETR receipts and Photos of the vehicle before and after
replacement of the windscreen if you have already replaced the windscreen/window glass
2 The cover afforded under the windscreen extension endorsement has come to an end as a result of
this claim and you need to reinstate it by paying additional premium.
1 Insured. | .....................................................................................................................................................................................................................
2 Postal Address / Postal Code / Town | ....................................................................................................................................................................
3 Telephone No. | ..........................................................................................................................................................................................................
4 Email Address. | .........................................................................................................................................................................................................
5 POLICY No. | ...............................................................................................................................................................................................................
6 Motor Vehicle Registration No. | ............................................................................................................................................................................
7 Make and Type of Vehicle | ......................................................................................................................................................................................
8 Date of Incident. | ......................................................................................................................................................................................................
9 Name of Driver. | ........................................................................................................................................................................................................
⓾ Full description of the incident.| ............................................................................................................................................................................
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⓫ Has any damage been caused to the vehicle other than the breakage of the windscreen/window glass? | YES ⃞ NO ⃞
If yes, state the damage ........................................................................................................................................................................
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I/We hereby certify that the above answers are true to the best of my/our knowledge.
NAME SIGNATURE & STAMP OF THE INSURED DATE
Company Stamp / Seal.
CLM/WSF/001
