Form
FLORIDA MOBILE GLASS (FMG) WINSHIELD CLAIM INFORMATION.
The following information is required by insurance companies to file a claim. Our office will file a claim for you.
Name
*
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Vehicle Address (Where To Install)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date Of Damage
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
*
example@example.com
Clear Picture Of Your Florida Insurance Card
*
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of
Stand In Center - Front Of Car, Picture Of Whole Windshield
*
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Windshield Ordering Purposes
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of
Picture Of The Windshield Damage, Close Up
*
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To Show Damage
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of
Sit Inside Vehicle, Take A Picture If The Winshield With The Mirror Area
*
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Windshield Ordering Purposes, Censors
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of
COMMENTS
Optional
The added information below is required only for Geico, State Farm, and USAA
Picture If Your Drivers License
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To Show You Are The Insured
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of
A Picture Of The Rear Of The Vehicle Showing The License Plate
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To Show It Is The Insured Vehicle.
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of
Name
First Name
Last Name
Submit
Should be Empty: