Submit a Claim

Sunday, September 05, 2010

Submit A Claim

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Please fill in all the fields and any other information you have and then press Submit which will send the form to us. Please view the whole form.

Required information is in Red

Insured Information

Insured First Name:

Insured Last Name:

Address:

City: State: Zip:

Best Day Telephone:

() -

Best Evening Telephone:

() -

(Sender's)Email Address:

Insurance Information

Insurance Company:

Policy #:

Insurance Agent/Agency:

Agency Phone #:

Comprehensive Deductible:

Accident Information

Date Damage Occurred (ex:09/01/2007):

Cause of Damage:

Glass Damage:

Who Was Driving?

Vehicle Information

If Year/Make/Model is not found, please check box and enter year/make/model in the comments field.

Year:

Make:

Model:

Vehicle Identification Number (VIN):

If work has already been done and you have the invoice,
please fax the invoice to 800-981-9891.

Comments

Note: Submitting a claim in no way denies or guarantees insurance coverage of your auto glass loss. After receiving your claim, we will take steps to determine if coverage exists. We will then contact you to schedule service with a convenient auto glass vendor.
Thank you for using our online claim service!

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