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.

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