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Central Valley

602.331.4527
West Valley

623.979.5300
East Valley

480.941.4091

Agent Glass Claim Form

Please complete the information below.  Accurate Auto Glass will contact the policy holder and do what ever is necessary to process the claim for you.

Agent Information

glass-car-small

First Name (required)

Last Name (required)

Agency

Phone Number

Insurance Company

Policy Number

Date or approximate date that damage occurred
(example: 01/01/2014

Additional Information: