Auto Glass Claim Form

 Customer Name: *Required
 Home Phone Number: - - *Required
 Work Phone Number: - -
 Cell Number: - -
 Email: *Required
 State:
* Required
 Address on Policy : *Required
 Insurance Company : *Required
 Policy Number : *Required
 17 Digit VIN Number :
Agency Name & Phone Number :
 Vehicle Information
 Make: ie) Chevrolet
 Model: ie) Silverado C3500
 Style: ie) 4 Door Crew Cab
 Year:
 Damage Information
 The piece of glass damaged is the: Windshield   Rear Glass
 Side Glass    Other
Date of Loss : Cause :
Full Glass : Deductible Amount :
 Additional Information:

If you experience any problems using this form, please email us at: sgwsupport@empireglass.us.