Job Request | New Zealand Auto Glass

// JOB DETAILS

Are you an insurance broker or insurance company?

Yes

No

Do you require a price before we proceed with the job?

Yes

No

Contact Email Address[*]

Order #

Job Priority[*]

// COMPANY DETAILS

Company Name[*]

Branch[*]

Branch (Other)

Contact Name[*]

Contact Mobile or Landline Number[*]

// VEHICLE DETAILS

Make[*]

Make (Other)[*]

Model[*]

Year[*]

Year (Other)[*]

Door Type[*]

Body Style[*]

Body Style (Other)[*]

Number Plate[*]

Work Required[*]

Work Required (Other)[*]

// FRONT WINDSCREEN FEATURE(S)

Rain sensor

Camera (Lane change warning system)

Heated wiper system

Windscreen antenna (Radio and/or GPS)

Check all that apply above

I have ensured that the information I have supplied in the front windscreen features section is accurate

// REAR WINDSCREEN FEATURE(S)

Privacy tinted

Check all that apply above

I have ensured that the information I have supplied in the rear windscreen features section is accurate

// SIDE / DOOR GLASS PART(S)

Driver's Side Front Door Glass

Passenger's Side Front Door Glass

Driver's Side Rear Door Glass

Passenger's Side Rear Door Glass

Driver's Side ¼ Glass in Rear Door

Passenger's Side ¼ Glass in Rear Door

Driver's Side ¼ Glass in Body

Passenger's Side ¼ Glass in Body

Check all that apply above

// IMAGE(S) UPLOAD

Upload up to THREE images of the damage

Maximum filesize of 4 MB per image

// JOB DETAILS

// COMPANY DETAILS

// VEHICLE DETAILS

// FRONT WINDSCREEN FEATURE(S)

// REAR WINDSCREEN FEATURE(S)

// SIDE / DOOR GLASS PART(S)

// IMAGE(S) UPLOAD

// COMMENTS / INFORMATION