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Insurance Claim for Windscreen Fitment
*Name
*Email
*Phone Number
Insurance Broker
Policy Number
Broker Email
Make of Vehicle
Model of Vehicle
Vehicle Year (Manufactured)
Rain Sensor?
Does your windscreen have a rain sensor?
.
Yes there is a rain sensor
.
No there is not a rain sensor
Services Required
— Select —
Windscreen Replacement
Chip Repair
Side or Rear Window Replacement
Other
Referred by:
If you received a flyer, what is the agent name on the flyer?
Where would you like the job done, onsite or at our workshop?
*Where would you like the job done, onsite or at our workshop?
Select the location option that is best for you
.
Onsite
.
At Fit My Windscreen Workshop (ZENA Auto, 96 Main Reef, Crown Mines (opposite Langlaagte Traffic Department)
Street Address
Suburb
City
Province
Message
Would you like to tell us anything else relating to this job?
Submit
