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Email
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Email 2
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Email 3
example@example.com
Address
Street Address
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City
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Please select your preferred time for your upcoming appointment.
Appointment
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Job Description
What type of service does your vehicle need?
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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.
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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 #:
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of
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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 $
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I AGREE
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