Submit an Insurance Claim

Please complete the form below and we will review your claim.

Step 1: Policyholder’s Information

  • Please enter insured's first name.
  • Please enter insured's last name.
  • This isn't a valid phone number.
    Please enter insured's primary phone number.
  • This isn't a valid phone number.

  • Preferred Contact Method*

    Please indicate your preferred contact method.
    Please indicate your preferred contact method.
  • This isn't a valid email address.
    Please enter insured's email address.
  • Please enter insured's address.
  • Please enter insured's city.
  • Please select insured's state.
  • Please enter insured's zip code.

Step 2: Insurance Information

  • Please enter insurance company.
  • This isn't a valid phone number.
  • Please enter insurance policy number.
  • Please enter insurance deductible.
  • *Portland Glass will assist the insured through the process of calling the network associated with the insurance company to help obtain this information.

Step 3: Vehicle Information

  • About The Vehicle:

  • Please enter vehicle year.
  • Please enter vehicle make.
  • Please enter vehicle model.

  • Glass To Be Replaced/Repaired

    • Please make a selection.

Step 4: Agency Information

  • Please enter agent's full name.
  • This isn't a valid phone number.
    Please enter agent's direct phone number.
  • This isn't a valid email address.
    Please enter agent's email address.

Step 5: Anything Else We Should Know?

*required field