Agent Claims Form

Insured's Information

Name *

First

Last

Insured's Phone Number *

Policy Number *

Insurance Company *

Claim Number

Vehicle Identification Number (VIN) *

Agent's Information

Agency Name *

Submitter's Name *

First

Last

Submitter's Email *

Submitter's Phone Number *

Additional Insured's Information (Optional)

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

Vehicle Information (Optional)

Which Glass?

select one

Vehicle Type

select one

Additional Info

Please Note: By providing a telephone number and submitting the form, you agree to Avizion Glass’s Terms of Use and Privacy Policy. You consent to receive phone calls and SMS messages from Avizion Glass- to provide updates and information regarding your business with Avizion Glass. Message frequency may vary. Message & data rates may apply. Reply STOP to opt-out of further messaging. Reply HELP for more information. See our Privacy Policy.