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.)?YesNoInsured's Name*Insured's Phone*Where work will be performed*In-ShopMobileCity where work is to be performed*Location*Select LocationColumbiaEugeneJefferson CityKansas 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 NeedRock Chip Repair - Smaller than a quarterRock Chip Repair - Larger than a quarterGlass ReplacementGlass to be repaired/replaced* Windshield Back glass Quarter glass Door glass Vent glass
