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

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Agent Form

Customer Information

Glass Coverage

Vehicle Information

Glass Needed

Agency Information