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Insurance Claim
You have the legal right to choose any glass fitment center want, don’t let your insurance agent or glass network tell you different (consumer act)
1
Your Details
2
Vehicle Details
3
Insurance Details
4
Your Appointment
Name
*
First
Last
Phone
*
Email
Branch Nearest You
Pretoria
Johannesburg
Polokwane
Rustenburg
Lesotho (Maseru)
Vehicle Make (eg. Toyota, BMW)
Vehicle Model (eg. Hilux, M3)
REG number:
VIN number:
Year
Which Window Was Broken
Windscreen
Rear Windscreen
Driver Side Window (Front Door)
Passenger Side Window (Front Door)
Driver Side Window (Rear Door)
Passenger Side Window (Rear Door)
INSURANCE COMPANY:
INSURANCE COMPANY TEL:
POLICY NO:
BROKER NAME (IF APPLICABLE):
BROKER TEL (IF APPLICABLE):
DATE WHEN DAMAGE OCCURED
WHEN WOULD YOU LIKE YOUR WINDOW REPAIRED
APPOINTMENT TIME
7am to 8am
8am to 9am
9am to 10am
10am to 11am
11am to 12pm
12pm to 1pm
1pm to 2pm
2pm to 3pm
4pm to 5 pm
5pm to 6pm
Urgent Appointment Required
Please note: If you need fitment urgently please tick box below and make sure all details has been supplied correctly and an agent will come back to you as soon as possible.
