Insurance Claim Form

Submit your insurance claim details and we'll handle the rest. We work directly with your insurance company to process your claim.

Customer Information

Full Name *

Phone Number *

Email Address *

Vehicle Information

Year *

Make *

Model *

VIN (Optional but recommended)

Insurance Information

Insurance Company Name *

Policy Number *

Policy Holder's Name *

Claim Number (Optional)

Service Details

Type of Glass *

Description of Damage *

Service Preference *

In-Shop @ 3424 Auburn Blvd, Sacramento, CA 95821 Mobile Service (We come to you)

Preferred Date & Time *

Optional

Photos of Damage

Upload photos of the damage (JPG, PNG, GIF accepted)

Authorization: By checking this box and submitting this form, you authorize Quality Auto Glass to contact your insurance company to process this claim on your behalf. *