Klein Dickert Auto Glass

The Right Choice Since 1919.

Our Mission: To exceed our customer expectations and remain successful through the safe, conscientious efforts of our most valuable asset, our employees.

Agent Claim Request Form

You can also print the Agent Claim Request form and fax it to us.

 
* = Required Fields
Agency Information
* Agency Name
 * Agency Phone
* Insurance Company
 * Name of Person Submitting Claim
* Email Address of Person Submitting Claim

Policy Holder Information
* Policy Holder Name
* Policy Holder Street
* Policy Holder City
 * Policy Holder State/Zip
   
* Policy Holder Telephone
Home      Work      Cell 
* Policy Number
 Claim Number
* Deductible Amount
$ 		Date of Loss
Cause of Loss

Vehicle Information
* Vehicle Year
* VIN (Vehicle Identification Number)
  (17 digits required)
* Vehicle Make
 * Vehicle Model
* Vehicle Type






Service Information
* Type of Work
If Other -

Send Claim to:





Special Instructions


Security Code
For added security we ask you to please enter the code
displayed below into the text box.
A confirmation e-mail will be sent to the person submitting the claim. If you do not receive the auto reply, please call or resubmit.

NOTE: Klein-Dickert will not share any information with any other company or organization.