Pekin Auto Glass Express Through Alliance
Please fill in all the fields and any other information you have and then press Submit which will send the form to us. Please view the whole form.
Required information is in Red
 
Insured Information
Insured First Name:
Insured Last Name:
Address:
City:   State:   Zip:
Best Day Telephone: () -
Best Evening Telephone: () -
(Sender's)Email Address:
 
Insurance Information
Policy #:
Insurance Agent/Agency:
Agency Phone #:
Comprehensive Deductible:
 
Accident Information
Date Damage Occurred (ex:09/01/2007): Show Calendar
Cause of Damage:
Glass Damage:
Who Was Driving?
 
Vehicle Information
Year:
Make:
Model:
Vehicle Identification Number (VIN):
 
Comments
Note: Submitting a claim in no way denies or guarantees insurance coverage of your auto glass loss. After receiving your claim, we will take steps to determine if coverage exists. We will then contact you to schedule service with a convenient auto glass vendor.
Thank you for using our online claim service!