Insurance Agent Claim

Insurance Agent Claim Form

Welcome to the agent claim submission form. Please complete the fields below to send your client’s claim information to Jolliff Glass Company.

Name (Policy Holder)

Phone No.

Policy No.

Claim No. (if available)

Deductible Amt.

Date of Loss

Insurance Carrier

Vehicle Year

Vehicle Make

Vehicle Model

Vehicle VIN No.

Body Type

Glass to be Replaced

Agency Name

Agency Phone

Email Address

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