Agent Claims Insurance Agency Name * Insurance Agency Contact Person First Name Last Name Insurance Agency Contact Person Phone (###) ### #### Insured Name First Name Last Name Insured Address Address 1 Address 2 City State/Province Zip/Postal Code Country Insured Phone (###) ### #### Insured Email Insured Policy # Insured Glass Deductible Date of Loss MM DD YYYY Vehicle Year Vehicle Make Vehicle Model Vehicle VIN Which glass is damaged? Windshield Back Glass Door Glass Quarter Sunroof Glass Vent Notes: Thank you!
