LOCK TIGHT GLASS AND SHUTTER SERVICE P/L

The Glass Repair Specialists

24 Hour Emergency Service

6 Haslam Street, Seaford 3198 (P.O. Box 340 Seaford Vic. 3198)

Telephone (03) 9782 4422 Fax (03) 9776 9178 Web Site www.locktight.com

YOUR DETAILS

Full Name (s)

 
Address include postcode

 
Policy Number Expiry Date Telephone Private Telephone Business

       
POLICY EXCESS Does your policy have an excess to be paid? YES / NO Amount $

If so have you paid the repairer the excess? YES / NO Amount $

DETAILS OF ACCIDENT

When did the damage occur? Date _______________Day ______________ Time ___________

When was it first discovered? Date _______________ Day ______________ Time ___________

Address where the damage occurred

 
Briefly state what happened and how the damage was caused

 
 
Have you reported the matter to the Police? YES / NO Report attached YES / NO

Give the name and address of the person(s) who may have been responsible for the damage

 
DETAILS OF DAMAGE

Describe the property damaged

 
What is the size of the glass damaged? _______mm X _____mm

DETAILS OF REPAIRS Have you authorised a repairer to start work? YES / NO

Have you paid the repairer for this work? YES / NO

Please send payment directly to the repairer? YES / NO

Name Address of Repairer

LOCK TIGHT GLASS AND SHUTTER SERVICE P/L

P O BOX 340 Seaford Victoria 3198

Declaration

I/We declare that the information and particulars given above are true and accurate in every respect.

Signature _________________________________________________ Date _______________________