a Date of breakage (dd/mm/yyyy) Time
am pm
b Address of the premises where the breakage occurred
c Describe fully how breakage occurred
d Was any person(s) responsible for breakage?
Yes No
If yes, say why
Name and address of person(s) responsible
f If they are insured against causing the damage, state Insurer’s
name, address and policy number
Circumstances of the Claim
Name of the Insured
Town County
Postcode Date Premium Paid
Occupation Telephone Number
Policy Number Value Added Tax. Are you
a registered person or company? Yes No
Please state the number of bedrooms (include all rooms designated as bedrooms even if not used as such)
You the Policyholder
a Type of premises (i.e: shop, flat, house etc.) b Were the premises unoccupied? Yes No
If yes, when last occupied?
General Information
Glass Claim Form
NIG Commercial Claims P O Box 1151 Bromley BR1 9WB
Please note - you can complete this form on screen. When completing please use the tab and arrow keys to move between the relevant
fields. Ensure you do not use the return or enter keys.
If completing by hand, please answer all questions using BLOCK CAPITALS.
c Are you the owner of the premises? Yes No
If no, give name/address of owner
Are you responsible for replacement of the glass?
Yes No
e Is there any other policy in force providing cover for this incident?
Yes No
If yes give details to include Insurers name/address and policy number
Were the police notified? Yes No
If yes, address of station
Date of notification to police Police Crime Reference No
eneral Information
Number of pieces
Description of Broken Glass
Position, i.e. window, door, etc. Type/thickness Size in metres (m) Cracked or broken?
I/We declare that no material information has been withheld and that all statements on this form are true to the best of my/our knowledge and belief.
In addition the articles and property belong to the persons named and no other person has any interest whether as Owner, Mortgagee or Trustee.
I/We understand that you may seek information from other insurers to check the answers I/we have provided, and I/we authorise the giving of such
information for such purposes.
Insurers and their agents share information with each other to prevent fraudulent claims and to decide whether to accept your proposal and,
if so, on what terms via the Claims and Underwriting Exchange Register, operated by Insurance Database Services Ltd. A list of participants
is available on request. The information you supply on this form, together with the information you have supplied on your application form
and other information relating to the claim, will be provided to participants.
Signature Date (dd/mm/yyyy)
Please complete and return this form as soon as possible. Damaged property should be protected from further deterioration but not disposed of
without prior reference to the Company. If the claim is for repairable damage i.e. buildings, a Trademan’s estimate will be required.
NIG policies are underwritten by U K Insurance Limited, Registered office: The Wharf, Neville Street, Leeds LS1 4AZ.
Registered in England and Wales No 1179980. U K Insurance Limited is authorised by the Prudential Regulation Authority
and regulated by the Financial Conduct Authority and the Prudential Regulation Authority.
Calls may be recorded.