Windshield Repair/Replacment Scheduling Form
Sport Utility Vehicle (SUV)
Minivan or Van
VIN (Last 8 Characters)
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
Check Wipers (optional upgrade)
Any Special Instructions
Where is Vehicle Located?
Street Address Line 2
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
Should be Empty: