Windshield Repair/Replacment Scheduling Form
Vehicle Type
Sedan
Sport Utility Vehicle (SUV)
Minivan or Van
Pickup Truck
Large Truck
Other
VIN (Last 8 Characters)
Year
Make
Model
Damage Information
If windshield has crack or damage less than 6 inches (size of dollar bill), it may be able to be REPAIRED. If damage is larger than 6 inches or in driver's direct field of vision windshield will likely need to be REPLACED. Please check appropriate box below.
Type of Services
Repair Windshield
Replace Windshield
Check Wipers (optional upgrade)
Any Special Instructions
Heading
Authority Name
Contact Name
First Name
Last Name
Phone Number
Email
example@example.com
Where is Vehicle Located?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
If windshield is replaced, you will be required to pay the $250 deductible. Please submit evidence of repair to GHARRP so that we can invoice appropriately.
*
Member Authority agrees that they are responsible for deductible cost, if any
Book Now
Should be Empty: