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1.800.365.9922
Residential Glass
Request a Quote
Residential Online Showroom
Shower Enclosures and Doors
Window Repair and Replacement
Mirrors
Table Tops and Shelves
Glass Edge Options
Sliding Glass Doors
Screens
Skylights
Decorative Glass
Kitchen Backsplashes and Countertops
Auto Glass
Request a Quote
Auto Glass Online Showroom
Windshields
Chip Repair
Side and Back Glass
RV Windows
Sun Roofs
Rear Sliding Windows
Side and Rear View Mirrors
Custom Windshields
Insurance Claims
Commercial Glass
Request a Quote
Cooperative Contracts
Commercial Online Showroom
Emergency Board Up Services
Store Fronts and Entrances
Door Repair
Curtain Wall
Interior Office
Handrails
Decorative Glass
Security Glass
Careers
Contact Us
Find a Location
History
About Us
Automotive Customer Feedback
Residential Customer Feedback
Agent Claim Form
National Accounts
Blog
Get a Quote
Find a Location
1.800.365.9922
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Agent Submission Form
Agent Submission Form Auto
Agent Submission Form Auto
*
First Name
*
Last Name
*
Address
*
City
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*
Zip
*
Best Phone
### ### #### (Please don't use dashes or parentheses)
Alternative Phone
Email Address
*
Insurance Company
*
Policy Number
*
Date of Loss
January
February
March
April
May
June
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August
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December
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1923
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1919
1918
*
Cause of Loss
Road Debris
Weather
Collision
Theft
Vandalism
Tree/Branch
Unknown
*
Does the Windshield need replaced or repaired?
Repair
Replace
Not Sure
Repair, Replace, Not Sure or leave blank if not applicable
*
Damaged Glass Location
Please briefly describe which glass on the vehicle is damaged with any other notable information.
*
Glass Coverage
Yes
No
*
Deductible
*
Agency Name
Agent Name
*
Agent Telephone Number
Agent Email
*
Vehicle Year
*
Vehicle Make
*
Vehicle Model
Vehicle Style
(Ex. 2 door, 4 door, Minivan etc.)
Vehicle VIN
Special Instructions
* = required