Glass Claim Contact Information
What is your first name?
What is your last name?
What is your email address?
What is the preferred phone number for this glass claim?
Will you be the primary contact for this glass claim?
Who will the primary contact be?
What is their phone number?
What is their email address?
What is the year, make and model of the vehicle with glass damage?
How many doors does this vehicle have?
Does this vehicle have any advanced driver assistance systems(ADAS)? (Ex. Forward collision warning,
lane departure warning, blind spot warning light, and
adaptive cruise control)
What is the address where this vehicle is garaged?
What date did you first noticed the glass damage?
MM slash DD slash YYYY
Please select the damaged glass type(s). (Select all that apply)
What other type of glass was damaged?
Please upload a picture of the full pane of damaged glass.
Please provide a brief description of what caused the damage.
Has the glass already been repaired?
Please upload a copy of the invoice for the repairs.
Please select the appropriate payment method for this glass claim.
Glass Repair Preferences
What is your preferred repair solution? (Conditions may apply)
What is your office address?
Does your office have an enclosed area that provides protection from the weather where repairs can be done?
What is the name of the dealership?
What is the dealership's phone number?
What is the address of the dealership?
What is the name of the auto glass shop?
What is the auto glass shop's phone number?
What is the address of the auto glass shop?
What is the address of the other location where you would like to conduct the glass repair(s)?
Please use this field to upload any other relevant information for this new residence. (i.e. mortgage requirements, elevation certificates, wind mitigation form, etc.).
Max. file size: 128 MB.
Drop files here or
Please enter any additional remarks in the space below.
Disclaimers: Any claim handling preferences selected in this form may not be available for this claim. Repair procedures will be determined by auto glass repair professionals, type of glass being repaired and other applicable conditions.
This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.
Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes.