Stephens Auto Glass

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Online Claim Form

The below form is intended to be used by insurance agencies or the insured to submit the insured’s complete information to our shop in order for us to assist them in filing a glass claim. Submitting this form DOES NOT create a claim with any insurance company.

Insurance Information




















Contact Information










Vehicle Information









Possible Repair (Quarter size or smaller damage)
Replace


Car
Truck
SUV
Van


2 Door
4 Door
Coupe
Sedan
Convertible
Hatchback
Station Wagon


Standard
Extended
Super
Crew
Extended Crew
2 Wheel Drive
4 Wheel Drive
1500
2500
3500


2 Door
4 Door
2 Wheel Drive
4 Wheel Drive


Mini
Full Size

Glass Damage Information


Front Windshield
Door Glass
Back Glass
Quarter Glass
Vent Glass


Front Windshield
Door Glass
Back Glass
Quarter Glass
Vent Glass
Side Glass


Front Windshield
Door Glass
Back Glass
Quarter Glass
Vent Glass
Sliding Glass


Front Drivers Side
Front Passengers Side
Rear Drivers Side
Rear Passengers Side


Tempered (Shattered into little pieces)
Laminated (Cracked or Chipped)
Sliding Door
Acoustic Interlayer (Noise Reduction)


Green Tint
Gray
Other/Unsure


Green w/ no band but black
Green w/ blue shade band
Green w/ green shade band
Green w/ gray shade band
Blue w/ no band but black
Blue w/ blue shade band
Blue w/ gray shade band
Gray w/ no band but black
Gray w/ gray shade band
Other/Unsure


Stationary
Moveable(Power)
Moveable(Manual)


Drivers Side
Passengers Side


Stationary
Slider(Power)
Slider(Manual)


Super Duty
F150
Ram Logo
Jeep/Mopar Logos


Antenna
On Star
Rain Sensor
Remote Start
Humidity Sensor
Head-Up Display (HUD)
Lane Departure Warning
Forward Collision Alert
Electrochromic Mirror (dims)
Acoustic Interlayer (Noise Reduction)


Wiper
Heated
Remote Start
On Star
Antenna


Please provide any additional information.


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Online Claim Form

See why more and more people are turning to Stephens Auto Glass

Stephens Auto Glass Peoria
2526 N Sterling Ave Peoria, IL 61604
(309) 686-4100
Fax: (309) 686-1424
Toll Free: (888) 686-1400
Stephens Auto Glass Pekin
1540 Sheridan Rd Pekin, IL 61554
(309) 353-6674
Fax: (309) 353-6825
Toll Free: (800) 353-6674
Stephens Auto Glass Bloomington/Normal
1504 E Vernon Ave Normal, IL 61761
(309) 451-3317
Fax: (309) 451-3608
Toll Free: (877) 213-3317
Stephens Auto Glass Decatur
2995 N Oakland Ave Decatur, IL 62526
(217) 877-5502
Toll Free: (888) 644-4436
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