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Glass Claim
Please complete the form for your Glass claim
INSURED DETAILS
Policy Number
*
VAT Registration Number
Name
ID Number
*
Occupation
*
Phone
*
Email Address
*
Plot Number
Ward /Locality
City
OCCURRENCE
Date
Time
Hours
Minutes
Name and address of person responsible for breakage
Name and address of witnesses
PREMISES
Address of premises where breakage occurred
Address of premises where breakage occurred
Plot, Apartment, etc
City
Country
Afghanistan
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Argentina
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Bouvet Island
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British Indian Ocean Territory
Brunei
Bulgaria
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Burundi
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Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China, People's Republic of
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
France, Metropolitan
French Guiana
French Polynesia
French South Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
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Guatemala
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Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Island
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Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Johnston Island
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
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Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
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Netherlands Antilles
New Caledonia
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Niger
Nigeria
Niue
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North Macedonia
Northern Mariana Islands
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Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
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Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Reunion Island
Romania
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Rwanda
Saint Helena
Saint Kitts and Nevis
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South Georgia and South Sandwich
Spain
Sri Lanka
Stateless Persons
Sudan
Sudan, South
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan, Republic of China
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America (USA)
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna Islands
Western Sahara
Yemen
Zambia
Zimbabwe
Were premises occupied?
Select
YES
NO
If Yes, By whom?
Purpose for which occupied
VEHICLE
Vehicle Make
Model
Registration no.
Year
Windscreen tinted or clear and shatterproof or amour plate?
Driver’s name
Licence no.
Place Issued
Date issued
DETAILS OF BROKEN GLASS
Full description of broken glass
Size and thickness in millimetres
Cracked or shattered?
Any signwriting or broken glass?
VALUE
Total value of all insured glass
When last valued?
OTHER INSURANCE
Is there any other insurance covering the broken glass?
YES
NO
Select
If so, give name of insurer
DECLARATION
*
I/We solemnly declare that the above particulars are true and complete in every respect. By signing below, I agree and voluntarily consent to Sesiro's processing of the provided Information for the purposes of processing my claim, and I give Sesiro permission to do so, and any personal data (including sensitive personal data) will be processed in accordance with Sesiro's privacy policy available on its website, and I further understand that I am free to withdraw my consent on written notice to Sesiro, on legitimate grounds which are reasonable and compelling. I agree that the Information may be disclosed by Sesiro to third parties, including Sesiro's affiliates, service providers and associates (some of which may be located outside of Botswana).
SUBMIT CLAIM
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