WINDSHIELD CLAIM

Please fill out the claim form completely. Please include all information pertaining to this claim. All fields are required.

This claim form is not an authorization for the repair or replacement of windshields or repairs for any other claimed damages. This claim will not be reviewed unless all appropriate boxes are filled with information relative to the claim. Please note: If a field doesn't apply to your claim, type N/A in the box. Should you deem your claim repair/replacement costs to be immediate, submit your claim form to Kilgore Claims for liability evaluation and to your own auto/home insurance company for more expeditious handling. Thank you!


Owner / Claimant
Was the owner of the vehicle driving the vehicle at the time of incident? *
Owner's name *
Owner's name
Driver's license expiration date: *
Driver's license expiration date:
Owner's home phone *
Owner's home phone
Owner's business phone *
Owner's business phone
Owner's cell phone *
Owner's cell phone
Owner's address *
Owner's address
Insurance phone number *
Insurance phone number
Insurance policy expiration date *
Insurance policy expiration date
Registration expiration date *
Registration expiration date
Driver
Driver's Name
Driver's Name
Driver's License Expiration Date
Driver's License Expiration Date
Driver's Residence Phone
Driver's Residence Phone
Driver's Business Phone
Driver's Business Phone
Driver's Cell Phone
Driver's Cell Phone
Driver's Alternate Phone
Driver's Alternate Phone
Driver's Address
Driver's Address
Alleged Offending Vehicle
Incident Description
Incident Description (Date of incident) *
Incident Description (Date of incident)
Time of incident *
Time of incident
$
Full name of person who completed this form
Full name of person who completed this form
I understand that this claim form IS NOT AN AUTHORIZATION for the repair or replacement of windshields or repairs for any other claimed damages. Furthermore, this claim will not be reviewed unless all required fields have been completed and appropriate information, relative to the claim, has been provided. *