Submit an Insurance Claim

Step 1: Insured's Information

• Insured's Name *
  Please enter insured's first name.
• Insured's Last Name *
  Please enter insured's last name.
• Primary Phone *
  This isn't a valid phone number.

  Please enter insured's primary phone number.
• Alternative Phone
  This isn't a valid phone number.
• Email Address *
  This isn't a valid email address.

  Please enter insured's email address.
• Address *
  Please enter insured's address.
• City *
  Please enter insured's city.
• State *
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  Please select insured's state.
• Zip Code *
  Please enter insured's zip code.

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Step 2: Insurance Information

• Insurance Company *
  Please enter insurance company.
• Phone Number
  This isn't a valid phone number.
• Policy Number *
  Please enter insurance policy number.
• Deductible *
  Please enter insurance deductible.
• Date of Loss
• Cause of Loss
• Claim # or Network Referral #
• *Portland Glass will assist the insured through the process of calling the network associated with the insurance company to help obtain this information.

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Step 3: Vehicle Information

• About The Vehicle:

• Year *
  Please enter vehicle year.
• Make *
  Please enter vehicle make.
• Model *
  Please enter vehicle model.
• Style
• VIN Number

• Glass To Be Replaced/Repaired

• Replace Glass
  Please select one or more items you would like to have replaced.
  • Windshield
  • Front Door
  • Door Glass
  • Back Door
  • Vent Glass (on door)
  • Quarter Glass (on door)
  • Driver's Side
  • Passenger's Side
  • Back Glass
  • Other/Unsure

  Please make a selection.

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Step 4: Agency Information

• Agent's Name *
  Please enter agent's full name.
• Agency Name
• Address
• City
• State
  Select OptionAKALARAZCACOCTDCDEFLGAGUHIIAIDILINITKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPAPRRISCSDTNTXUTVAVTWAWIWVWY
• Zip Code
• Direct Phone Number *
  This isn't a valid phone number.

  Please enter agent's direct phone number.
• Email Address *
  This isn't a valid email address.

  Please enter agent's email address.

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Step 5: Anything Else We Should Know?

• Questions or Comments