Online Windshield Claim Form

Online WINDSHIELD Claim Form
Please Note: Fields marked with * are required fields.

Personal Contact Information
Name:*
Address:*
City:*
State:*
Zip Code:*
Phone:* (e.g. 000-000-0000)
Fax: (e.g. 000-000-0000)
Email Address:*

Vehicle Information
Model Year:* (e.g. 2007)
Vehicle Make:* (e.g. Ford)
Vehicle Model:* (e.g. Explorer)
VIN:*
Current Odometer:*

Warranty Registration Information

The prefix letter(s) and number are located at the top right corner of your Customer Registration Form.

Prefix:*

Number:*

Purchase Date:*

Dealership Name:*

Today's Date:*

Date you first noticed the damage:*

Describe, the damage to the windshield in detail (i.e. chip, star, crack, size, etc.)
and how the damage was sustained:

(Please Note: This claim cannot be processed without a detailed explanation of exactly how and when the damage has occurred.)

Type in the below box the area(s) of damage to the windshield based on the
"WINSHIELD DAMAGE ZONES" figure below: (e.g. I have damage to zones 1 and 2.)

Initials of Acceptance
		Please type your initialss to indicate: I am aware that PermaPlate Company LLC, Inc. relies on the information and statements above. I hereby certify that the above statements are complete and accurate to the best of my knowledge. Any fraudulent statements will result in invalidity of warranty.

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