*This form is for Insurance claims only.*

Claims submitted Monday - Friday by 4:00 p.m. will be confirmed the same day.

Agency/Contact Name

First Name

Last Name

Agency Phone Number

(###)

###

####

Agency Email

Insured's Name

First Name

Last Name

Insured's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Insured's Phone Number

(###)

###

####

Insured's Secondary Phone Number

*If Applicable.

(###)

###

####

Insurance Company

*Please type below what insurance company the customer is insured with.

Insured's Policy Number

Deductible Amount

Date of Loss

YYYY

Cause of Loss

Year of Vehicle

If year not listed, please select *other and type the year in comments section.

Make of Vehicle

If vehicle not listed, please select *other and type the make in comments section.

Model of Vehicle

In the field below, please type the model of the vehicle.

Vehicle Style/# of Doors

Vehicle VIN #

Type of Work Needed

CHIP REPAIR

WINDSHIELD

DOOR GLASS

VENT GLASS

QUARTER GLASS

BACK GLASS

*OTHER

Driver or Passenger Side?

*If you selected door, vent, or quarter glass from the above list, please select which side that glass is needed for from the boxes below. *LEAVE BLANK IF THIS DOES NOT APPLY.

Driver Side

Passenger Side

Comments