Get started quickly and easily by providing your information.
Full Name
*
Email
*
example@example.com
Tel
*
Please enter a valid phone number.
Email 2
example@example.com
Email 3
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please select your preferred time for your upcoming appointment.
Appointment
Note
Job Description
What type of service does your vehicle need?
*
Replacement
Service
Chip Repair
Replacement
Windshield
Side glass
Rear glass
Other
Chip Repair
Smaller than a Toonie (Under 2mm)
Bigger than a Toonie (2mm- 10mm)
Kindly upload the first two pages of your INSURANCE POLICY and a photo of the DAMAGED GLASS, ensuring the ENTIRE FRAME IS INCLUDED.
Uplade files
Drag and drop files here
Choose a file
Cancel
of
Year:
Make:
Model & Body Style:
Km:
VIN#
What Glass Has Been Damaged?
Windshield
Back/Rear
Door
Vent
Quarter
Sunroof
Mirror
Cause of Damage:
Flying objects
Vandalism
Other
Date of the Glass Damage:
-
Month
-
Day
Year
Date
For Office Use
PART #:
CLAIM#:
PO #:
Invoice #:
Clover Transaction #:
Supplier #:
Take Photo
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Attached file
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Pictures
Rental
Courtesy
QB
SUB
REW
Payment Details
Customer request for the OEM part:
Yes
No
After market and OEM Difference $
ICBC Deductible(Comprehensive) $
PLEASE READ THE FOLLOWING CAREFULLY
You authorize PJ Glass Inc to repair/replace and collect the necessary deductible/payment along with any vehicle movement required to complete the above job.
PJ Glass may use your insurance policy information for the purpose of processing your claim.
Third-party insurance is not accepted by PJ Glass.
By Checking this Box, You acknowledge that You have read this agreement and agree to pay $
*
I AGREE
How would you like us to contact you?
Please Select
Phone call
Text message
Email
Submit
Should be Empty: