Agents

Agent Submission Form

Submit your client's auto glass claim quickly and securely with Glass America. We make the process simple, efficient, and fully aligned with your commitment to customer care.

Customer Information

Customer Name*

Customer Address

Store Location - State*

Store Location - City*

Email Address

Phone

Date of Loss

Vehicle Information

Vehicle Identification Number (VIN)

Year

Make

Model

Vehicle #

Glass Needed

Comments

Insurance Details

Insurance Company

Policy #

Deductible

Agency

Agency Phone Number*

Glass America - Account Manager

Submitted By

Name

Email Address