Insurance Claim Request Form

Please complete and return with a copy of your current insurance certificate showing the expiry date of the policy and a copy of your insurance schedule detailing any policy excess, claims limit or other restrictions that may apply to your policy. Email: installationsalesoffice@psvglass.co.uk or by Fax: 01494 462675

Company Name:

Name of Insurer:

Policy Number:

Expiry Date:

Excess Amount / Claims Limit:

Name of Broke:

Broker Contact Details:

Vehicle Registration:

Make & Model:

Date of Damage:

How did the damage occur:

I the undersigned as an authorised representative of the company above am hereby requesting that PSV Glass & Glazing Ltd, recover the whole or part of the costs of the works from my nominated insurers as detailed above and if having done so, PSV Glass & Glazing Ltd is unable to recover the whole or any part of the invoiced costs (including VAT) from the nominated insurers within 60 days from the date of invoice, for any reason whatsoever, I understand that I will become liable to immediatley pay any outstanding amount directly to PSV Glass and Glazing.

Signed:

Print:

Date: