HQ Windscreens Insurance Claim Authorization Customer Full Name Vehicle Plate Number Vehicle Make & Model Insurance Provider —Please choose an option—AA InsuranceAMIStateTowerVeroNZICoveFMGTrademe InsuranceOther Policy/Claim Number Photo of Damage (Take photo on-site) I hereby authorize HQ Windscreens to carry out the repairs/replacement on my vehicle. I confirm that I have glass cover with the insurer named above and authorize HQ Windscreens to bill them directly. Customer Signature (Sign with finger) Tap 'Clear' if you need to re-sign. Date of Service Official Document: HQ Windscreens NZ
