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


(Use XXXXXXXXXX Format)


Insurance Information


Yes      No




Vehicle Information