Auto Glass Now Agent Form


This form is meant for INSURANCE AGENCY USE ONLY. If you are looking for a quote please refer to our Instant Quote page by clicking here or call one of our customer service representatives at 1-800-300-8884.

If you are an Insurance Agent, please complete the form below on behalf of your client. An Auto Glass Now representative will contact your client and take care of everything else. However, filling out this form does not signify that we are setting a claim, as we will need the insured present in order to do so.

If you have any questions, please give us a call at 1-800-300-8884.


* Indicates a required field

Customer Information


(Use XXXXXXXXXX Format)


Insurance Information


Yes      No




Vehicle Information