ACF DEMO 1 , Avizion Glass

ACF DEMO 1

This is the revised Agent Claim Form as you requested.

This is a COPY of the form. I DID NOT revise the ACTIVE form in any way yet.

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Name

First

Last

Insured's Phone Number

Policy Number

Vehicle Identification Number (VIN)

Insurance Company

Claim Number

Agency Name

Submitter's Name

First

Last

Submitter's Email

Submitter's Phone Number

Insured's Address

Address Line 1

Address Line 2

City

State

Zip Code

Vehicle Make

example: Ford

Vehicle Model

example: Mustang

Vehicle Year

type in the year vehicle was made

Date of Loss

Deductible

Cause of Loss

Reference Number

Which Glass?

select one

Vehicle Type

select one

Additional Info