Online Claim Form Fields marked with an * are required Disclaim 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 Insurance Information Name of Insurance Agency Agents Name Agent's Office Phone Agent's Email * Insurance Carrier Name of Person on Insurance Policy Policy Number * Deductible Amount Date of Loss Cause of Loss Divider Contact Information Contact Information Name Email Daytime Phone # Cell Phone # Address (Address Number, Street Name, City) Divider Vehicle Information Vehicle Information Vehicle Year Vehicle Make Vehicle Model Vehicle VIN * Glass Damage Type * Possible Repair (Quarter size or smaller damage) Replace Vehicle Type Car Truck SUV Van Glass Damage Information Glass Damage Information Glass Damage Area(s) Front Windshield Door Glass Back Glass Quarter Glass Vent Glass Closest Location * Peoria Pekin Normal Decatur Additional Info If you are a human seeing this field, please leave it empty.