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Get Started
Submit an Insurance Claim
Please complete the form below and we will review your claim.
Step 1: Policyholder’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.
Preferred Contact Method*
Call Me
Text Me
Please indicate your preferred contact method.
Email Me
Please indicate your preferred contact method.
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 *
Select Option
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
IT
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Please select insured's state.
Zip Code *
Please enter insured's zip code.
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.
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.
Step 4: Agency Information
Agent's Name *
Please enter agent's full name.
Agency Name
Address
City
State
Select Option
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
IT
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
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.
Step 5: Anything Else We Should Know?
Questions or Comments
Submit Form
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