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?

Notes:

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