Agent Form

This form is meant for INSURANCE AGENCY USE ONLY. If you are looking for a quote please call one of our customer service representatives at a shop nearest you.

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. Please keep in mind, 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.

Customer Information

First Name *
Last Name *
Email Address *
Address *
City *
State *
Zip Code *
Telephone Number * (Use XXXXXXXXXX Format)

Insurance Information

Insurance Company *
Policy Number *
Agent Name
Date of Loss
Cause of Loss
Glass Coverage *	Yes No
Deductible * (Numbers Only)

Vehicle Information

Vehicle Year *
Vehicle Make *
Vehicle Model *
Vehicle VIN
Comments

This form is meant for INSURANCE AGENCY USE ONLY. If you are looking for a quote please call one of our customer service representatives at a shop nearest you.

Customer Information

Insurance Information

Vehicle Information

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