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  Your Information
Fields in Red are Required
Name:
E-mail:
Telephone:
   
  Vehicle Information
Year:
Make:
Model:
Doors:
Body Style:
Replacement Part:
Color:
   
  Insurance Information
  Please fill out the information that is readily available to you; not all information is required but please include as much as you can. All information submitted is kept confidential.
Date of Damage:
How did the
damage happen?
Company:
Agent:
Agent's Telephone:
Policy Number:
Deductible:
   
  Insured Information
Name on File with Insurance Company:
Address on File:
Zip code where work will be performed:
Requested Appointment Date:
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24 hour advance notice is required.
Requested Appointment Time:
Comments:
 

I understand by law, I have the right to choose any legitimate repair facility and I have chosen Insta Auto Glass, LLC. to perform this work within my insurance companies’ pricing and procedures.
To my knowledge, I warrant this insurance claim to be valid (under state and federal laws) and I am responsible before the work is complete, to either confirm or cancel the claim listed herein. I understand my insurance will contact me before any work is complete to finalize this claim before installation by Insta Auto Glass, LLC. and any rebate given is at the discretion of Insta Auto Glass, LLC. and our valued customer listed.

 

 

 

 

 

 

 

 

 

   
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