Online Claim Form Insurance Information Name of Insurance Agency: Agents Name: Agent’s Office Phone #: Insurance Carrier: Name of Person on Insurance Policy: Policy Number: Deductible Amount: Date Of Loss: Cause Of Loss: Contact Information Name: Daytime Phone #: Cell Phone #: Address: Vehicle Information Vehicle Year: Vehicle Make: Vehicle Model: Glass Damage Type: Possible Repair (Quarter size or smaller damage) Replace Vehicle Type: Car Truck SUV Van Car Type (select all that apply): 2 Door 4 Door Coupe Sedan Convertible Hatchback Station Wagon Truck Type (select all that apply): Standard Extended Super Crew Extended Crew 2 Wheel Drive 4 Wheel Drive 1500 2500 3500 SUV Type (select all that apply): 2 Door 4 Door 2 Wheel Drive 4 Wheel Drive Van Type (select all that apply): Mini Full Size Glass Damage Information Glass Damage Area(s): Front Windshield Door Glass Back Glass Quarter Glass Vent Glass Glass Damage Area(s) (Van): Front Windshield Door Glass Back Glass Quarter Glass Vent Glass Side Glass Glass Damage Area(s) (Minivan): Front Windshield Door Glass Back Glass Quarter Glass Vent Glass Sliding Glass Glass Location: Front Drivers Side Front Passengers Side Rear Drivers Side Rear Passengers Side Glass Information: Tempered (Shattered into little pieces) Laminated (Cracked or Chipped) Sliding Door Acoustic Interlayer (Noise Reduction) Glass Color: Green Tint Gray Other/Unsure Windshield Glass Color: 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 Quarter Glass Information: Stationary Moveable(Power) Moveable(Manual) Quarter Glass Location: Drivers Side Passengers Side Truck/SUV Back Glass Info: Stationary Slider(Power) Slider(Manual) Truck/SUV Windshield Info: Super Duty F150 Ram Logo Jeep/Mopar Logos Windshield Features: 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) Backglass Features: Wiper Heated Remote Start On Star Antenna Closest Location(required): Select…PeoriaPekinNormal Please provide any additional information. Additional Info: