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Portland Glass of Farmington
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Submit an Insurance Claim through
Portland Glass of Farmington
Please complete the form below and we will review your 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 *
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Please enter insured's primary phone number.
Alternative Phone
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Email Address *
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Address *
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City *
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State *
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Zip Code *
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Step 2: Insurance Information:
Insurance Company *
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Phone Number
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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
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WV
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Zip Code
Direct Phone Number *
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Email Address *
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Please enter agent's email address.
Step 5: Anything Else We Should Know?
Questions or Comments
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