Agent Claims Form

Insured's Information

Name *

First

Last

Insured's Phone Number *

Policy Number *

Vehicle Make *

example: Ford

Vehicle Year *

type in the year vehicle was made

Insurance Company *

Claim Number

Vehicle Model *

example: Mustang

Agent's Information

Agency Name *

Submitter's Name *

First

Last

Submitter's Email *

Submitter's Phone Number *

Additional Insured's Information (Optional)

Insured's Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of Loss

Deductible

Cause of Loss

Reference Number

Vehicle Information (Optional)

Vehicle Identification #

Which Glass?

select one

Vehicle Type

select one

Additional Info

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