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1
Claim Information
2
Claimant Information
3
Drivers Information
4
Offending Property/Vehicle
5
Claimant Affected Vehicle
6
Success
Claim Type
*
Property
Vehicle
Windshield
Company - Name
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Date And Time Of Incident
*
*
Do you have estimate of repair?
*
Do you have estimate of repair?
No
Do you have estimate of repair?
Yes
Name of person who completed this form
*
Incident Description
*
*
Location Of Incident
*
*
Disclaimer
*
I understand that this claim form IS NOT AN AUTHORIZATION for the repair or replacement of windshields or repairs for any other claimed damages. Furthermore, this claim will not be reviewed unless all required fields have been completed and appropriate information, relative to the claim, has been provided.
Disclaimer
No
Disclaimer
Yes
Claim Status
*
New
Open
Pending
Closed - Paid
Closed - Denied
Creating
