Schedule an auto glass repair or replacement appointment for your claimant. Fill out the form below and we will contact you shortly.

Alternatively, you may send requests via email to agent@cityautoglass.com, or use our Live Assistance service by clicking the Live Assistance link located on the left side of this page. Attachments are accepted with both.

*If you do not receive a confirmation email or your policyholder has not been contacted within 30 minutes please call us at (888) 552-4272.

*Referrals sent after 5:00 PM weekdays or on weekends will be called in the morning on our next business day. 

The forms on this site are not supported by your browser. Please email us at agent@cityautoglass.com, use our Live Assistance, or call us at 888-552-4272 and we will be happy to assist.

Updating your browser will allow you to use the forms on this site. Current versions of popular browsers can be downloaded via the following links:

Internet Explorer
Mozilla Firefox
Google Chrome

Fields marked with an asterisk (*) are required.

A few items need your attention. Please review the form and submit again.


Please enter a name



Please enter a phone number





Please include a ZIP Code

Please check a ZIP Code


Please enter your company name


Please enter your name or your agency name


Please include your email address

Please check your email address




Please include a policy number


Please include the deductible amount








Please include the VIN


Processing…

Your message was sent successfully. Thank you!

Schedule Another Client for Service