Paul's Auto Glass Insurance Invoice

Paul's Auto Glass

15 Paint St. Unit #2, Port Hawkesbury Nova Scotia B9A 3J5

Tel:(902) 625-0713 Fax:(902)625-0602

Installer

HST Registration No.

Invoice to:

(Customer's Information, Name, address ect.)

Telephone

(Customer's telephone number)

Automobile Make

(Click to choose make)

Automobile Model

(Type out model number)

Automobile Year

(Click to choose year)

Other Year

(Type out year if not found in above dropdown)

Doors

(Click to choose door number)

Odometer

(Type out)

License Plate

(Type out)

V.I.N. #

(Type out)

Policy Number

(Customer's insurance policy number)

Claim Number

(Customer's claim number)

Insurance Company

(Click to select the insurance company)

Insurance Company

(Type out if not listed above)

Insurance Agent Name

Insurance Agent Phone Number

Deductible

(Type out the customer's deductible. What they pay)

Cause of Damage

Location of Damage

Date of Loss

Date

Calibration performed?

Calibration Performed by:

(Who performed it?)

Calibration For

(Leave as Paul's Auto Glass)

Sales Item 1

Qty

(Click to choose Qty. It will usually be 1)

Part Number/Item Disc.

(Type out part number and description of part.)

Glass Cost

Kit Cost

Labour Cost

Sales Item 2

Qty

(Click to choose Qty. It will usually be 1)

Part Number/Item Disc.

(Type out part number and description of part.)

Glass

Kit

Labour

Sales Item 3

Qty

(Click to choose Qty. It will usually be 1)

Part Number/Item Disc.

(Type out part number and description of part.)

Glass

Kit

Labour

Sales Item 4

Qty

(Click to choose Qty. It will usually be 1)

Part Number/Item Disc.

Glass

Kit

Labour

Payment Summary

Subtotal

(Automatically fills out)

NS HST

(Automatically fills out)

HST Cost

(Automatically fills out)

Total

(Automatically fills out)

Deductible

(Write out customer's deductible)

Insurance Pays

(Automatically fills out)

Total Cost (Customer Pays)

(Automatically fills out)

90 Day warranty due to pressure crack.

Lifetime warranty against leaks not due to rust.

Authorization to pay. I herby authorize the above named insurance company to pay the full amount of this invoice under the above policy. Upon such payment, all rights I may have for claim and damand of loss of damage described above against the above named insurance company shall be therefore discharged. In the event that the insurance company does not make timley payment according to the terms of this invoice, I accept full responsibility for suach payments.

Customer's Signature

Date