Online Claims Center - Autoglass Claims Team Inc.

^* Denotes required fields.

STORE INFORMATION

A.C.T. STORE NUMBER ^*

TECHNICIAN NAME (OPTIONAL)

SHOP INVOICE NUMBER (OPTIONAL)

REPLACEMENT DATE MM/DD/YYYY ^*

CUSTOMER INFORMATION

CUSTOMER'S NAME ^*

INSURANCE COMPANY ^*

CUSTOMER'S STREET ADDRESS ^*

CUSTOMER'S CITY ^* STATE^* ZIP^*

CUSTOMER'S HOME PHONE NUMBER XXX-XXX-XXXX ^*

CUSTOMER'S ALT PHONE NUMBER XXX-XXX-XXXX

VEHICLE INFORMATION

VEHICLE YEAR XX ^*

VEHICLE MAKE ^*

VEHICLE MODEL ^*

VEHICLE BODY STYLE ^*

DAMAGE DATE MM/DD/YYYY ^*

VEHICLE VIN# ^*

AGENT INFORMATION

AGENT'S NAME

AGENT'S PHONE NUMBER XXX-XXX-XXXX

POLICY NUMBER ^*

DISPATCH/APPROVAL NUMBER ^*

REPLACEMENT INFORMATION

WINDSHIELD PART#

MOULDING PART#

MISC PART#1

MISC PART#2

TAX%

CUSTOMER DEDUCTIBLE

CLAIM NOTES

ADDITIONAL NOTES

Online claims center is a service provided by Autoglass Claims Team Inc. All claims submitted through Online claims center must be pre-authorized and can only be submitted by auto glass repair centers that have an A.C.T. services agreement on file with Autoglass Claims Team Inc. Autoglass Claims Team Inc. is not responsible for any typographical errors or misinformation entered by the glass center, in the event of any discrepancies on claims entered through Online claims center Autoglass Claims Team Inc. will make every attempt to notify the glass center to correct the matter. In the event that additional claims support extends beyond seven minutes additional charges may apply. Standard pricing for use of the Online Claims Center will corrospond to which plan the glass center has signed up for in their A.C.T. Services Agreement per claim; in the event of extended claims support beyond seven minutes claims processing fees will not exceed $12.95 per claim. To file an A.C.T. services agreement, contact A.C.T. at 1-888-228-9108 or click here to download the necessary forms. Claims processing services provided by Autoglass Claims Team Inc. are only available for glass repair shops within the United States who are filing claims with insurance carriers within the United States.