Agent Form – Mr. Glass

Open hours: Mon - Fri: 8am - 5pm

585-271-1270
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Agent Form

Agent Form

Agent Form

For Insurance Agency Use Only

For all other quote requests and questions regarding glass service, please revert to our form on the homepage.

Insurance Agents - Please complete the Agent Form below in order to let us know that your client needs glass work done. A customer service representative will then contact your client and take care of everything. Or if you prefer you can download the Mr. Glass form and fax it back to us at 585-278-1279.

Any questions? Give us a call at 585-271-1270

*Indicates fields that are required.

Agent Form

Customer Information

Name *

Phone *

Address *

Insurance Company *

Policy Number *

Date of Loss *

Cause of Loss *

Glass Coverage *

Yes

No

Deductible *

Vehicle Information

Vehicle Year *

Vehicle Make *

Vehicle Model *

Vehicle VIN *

Glass Needed *

Windshield

Backglass

Driver Front Door

Driver Rear Door

Passenger Front Door

Passenger Rear Door

Driver Vent

Passenger Vent

Driver Quarter

Passenger Quarter

Agency Information

Agency Name *

Contact Name *

Contact Email *

Contact Phone *

Agency Comments *

If you are human, leave this field blank.

Career Opportunities

Do you have what it takes to work in a fast paced environment with leaders in Glass Repair? Contact us today or fax your resume (585-271-1279).

Our Headquarters

835 East Main Street
Rochester, NY 14605

Contact

Tel: (585) 271-1270
Fax: (585) 271-1279

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