Patriot auto glass app Larry

PATRIOT AUTO GLASS

Windshield Replacement App

We offer you a NO COST Windshield Replacement with your Florida Comprehensive Insurance policy. ZERO DEDUCTIBLE! Our experienced & friendly auto glass technicians will come to your location, home or office, for your convenience. This form starts the insurance claims process. Our office will take care of the insurance claims for you so you can relax. Please use one form per vehicle. Check your email after you submit this form for further instructions and confirmation. Our office will call you to confirm your windshield installation date and time, usually the next day if possible. If you have questions please call 407-316-2662. Use this App 24/7.

Let's Get Started!

Contact Name*

First NameLast Name

Company Name

Only if you are a Company. (Optional)

Insured Name*

Who's name is the policy under?

Phone Number*

Primary Contact Number. Cell Phone Preferred.

2nd Phone Number

2nd Contact Number. (Optional)

Email*

example@example.com

Do you have Florida Comprehensive Insurance?*

Must Have Florida Comprehensive Insurance

Personal or Business*

Customer Type

Address Where Vehicle Will Be*

Street Address (HOME OR OFFICE)

Street Address Line 2

CityFlorida Only

Postal / Zip Code

Date of Damage*

What was the date of damage to your windshield?

What Day Would You Like To Request For Your Windshield Replacement?

Closed On Sundays & Federal Holidays. This is a request We will call you to confirm.

Vehicle Year, Make, Model*

Year - Make - Model

VIN Number:

Vehicle Identification Number

Please give a brief description of the windshield damage (Size and Location), special features of the windshield, and sensors. (Rain Sensors, Forward Collision Alert Sensors, Etc.). Manufacturer Decals*

We need the keys and someone to sign. Please leave the name and phone number of another contact person in case you are not home. Additional Instructions:

File Upload - Proof of Insurance & Vehicle Registration (2 Documents) PDF or Image File*

All personal vehicle we need a picture of the insurance card. Business Customers need the insurance certificate page with the vehicle info & Vin# listed.

File Upload - At least 3 pictures of the windshield damage. 7 Images Max.*

Windshield Damage Pictures. One close up picture, one picture showing the whole front of the windshield, and one picture from the inside while sitting in the driver's seat of the whole windshield. (7 Picture Max)

Referred By:

If you were referred, please let us know. (Optional)

Please verify that you are human*

After you submit we will order order the windshield glass. We will call you with the date and time that the auto glass technician will be at your location. Check your email after you submit this form for confirmation and instructions. Thank you for choosing Patriot Auto Glass.