Agent Submission Form
 

Indianhead Glass, Inc Has Been Serving Eastern
Minnesota and Western Wisconsin Since 1981
Agent Submission

Simply fill in the blanks and click the "Submit" button.
Fields marked with an asterisk (*) are mandatory and must be filled-in to process the form.

A customer service representative will then contact you by phone to schedule service within 24-48 hours.
 

- Insured's Information -

* Fields with an asterisk is required information
 
Insured's Name:*
Insured's Address:
Insured's City:
Insured's State:
Insured's Zip:
Best time to call your
customer:*
Phone Day Time:*
Phone Evening:*

- Insurance Information -

Email Address:*
Insurance Company:*
Agency:*
Agency Contact:*
Agency Phone:*
Policy Number:*
Claim Number:
Deductible:
Cause of Loss:
Date of Loss:
Network Ref Number:

- Vehicle Information -
Year / Make: Year  Make
Model: Model
 
Type:
VIN Number:
Choose which glass is broken:
 Comments

 

 

 
 
 

OUR LOCATIONS: 
ST. CROIX FALLS   HUDSON    NEW RICHMOND
 

Copyright © 2008 INDIANHEAD GLASS, Inc.,  All rights reserved