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Insurance Agent Claim Submit

Welcome to the agent claim submission form. Please complete the fields below to
send your client's claim information to Jolliff Glass Company. * indicates required field.

Please note that fields with an asterisk (*) are required.

Insured Information

*Name:(policy holder)

*Phone #:

*Policy #:

Claim # (if available):

*Deductible Amt.:

*Date of Loss:

*Insurance Carrier:

Vehicle Information:

*Year:

*Make:

*Model:

*VIN #:

*Body Type:

*Glass to be Replaced:

Agency Information:

*Agency Name:

*Phone #:

*Email Address:

Comments:

Auto Glass Services

Windshield Replacement
Windshield Repair
Mobile Auto Glass Services
Insurance Claims Welcomed
Limited Lifetime Warranty
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Our Location

Jolliff Glass Company

1700 W. Pioneer Parkway
Peoria, Illinois 61615
ph# 309.692.3511
ph# 800.692.0092

Monday - Friday
8:00 a.m. - 4:30 p.m.

Closed Saturday & Sunday