Agent Claims

So we can better serve you, please provide as much information as you can on this form.
We will call the insured as soon as possible and process their claim.
Castle Auto Glass

AGENT INFORMATION:  
Name of Agency * REQUIRED
Submitter Name * REQUIRED
Submitter Phone * REQUIRED

INSURED INFORMATION:  
Name * REQUIRED
Address
Address ( Line 2 )
City
State
Zip
Home Phone Number
Work Phone Number
Mobile Phone Number

INSURANCE COMPANY:  
Name of Company * REQUIRED
Policy Number * REQUIRED
Deductible
Claim Number (if needed)
Date of Loss
Cause of Loss
Reference Number (if available)

VEHICLE INFORMATION:  
Select glass that needs repaired/replaced
Vehicle Identification # * REQUIRED
Vehicle Type * REQUIRED
Vehicle Year * REQUIRED
Vehicle Make * REQUIRED
Vehicle Model (if Make was Mazda: enter Mazda 3, Mazda 6, etc.)
2-door 4-door  
Additional Information
   
* required items