Agent Claim Form Agent name* Agent's Phone*Has claim been called in to your third party billing network (i.e. SGC, LYNX, HSG, etc.)? Yes No Insured's Name* Insured's Phone*Where work will be performed* In-Shop Mobile City where work is to be performed* Location*Select LocationColumbiaEugeneJefferson CityOsage BeachSedaliaSpringfieldVehicle Year* Vehicle Make* Vehicle Model* Vehicle Style*Select Style2-dr Utility4-dr Utility2-dr Convertible4-dr Sedan4-dr Station Wagon2-dr Couple2-dr Hatchback4-dr Hatchback2-dr Extended Cab4-dr Crew Cab4-dr Quad Cab2-dr StandardI Need Rock Chip Repair - Smaller than a quarter Rock Chip Repair - Larger than a quarter Glass Replacement Glass to be repaired/replaced* Windshield Back glass Quarter glass Door glass Vent glass Δ
