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Agent Form

Agent Form

For Insurance Agency Use Only

For all other quote requests and questions regarding glass service, please click here.

Insurance Agents:

Please complete the Agent Form below in order to let us know that your client needs glass work done. A customer service representative will then contact your client and take care of everything.

Any questions? Give us a call at 585-343-0277.

Customer Information

Name*

Phone*

Address*

Insurance Company*

Policy Number*

Date of Loss*

Cause of Loss*

Glass Coverage*

Yes

No

Deductible*

Vehicle Information

Vehicle Year*

Vehicle Make*

Vehicle Model*

Vehicle VIN*

Glass Needed*

Windshield

Backglass

Driver Front Door

Driver Rear Door

Passenger Front Door

Passenger Rear Door

Driver Vent

Passenger Vent

Driver Quarter

Passenger Quarter

Agency Information

Agency Name*

Contact Name*

Contact Phone*

Contact Email*

Agency Comments*

Our knowledgeable team is ready to provide expert guidance and outstanding service, ensuring you get the results you're looking for.

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600 Ellicott Street
Batavia, NY 14020 View Directions

HOURS

Monday - Friday
8:00am - 4:00pm

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