Job Request This form is intended for use by NEW ZEALAND AUTO GLASS account holders only. [*] Denotes a required field. // JOB DETAILSAre you an insurance broker or insurance company?YesNoDo you require a price before we proceed with the job?YesNoContact Email Address[*]Order #Job Priority[*]Please selectAt earliest convenienceASAP (genuinely urgent request)// COMPANY DETAILSCompany Name[*]Branch[*]Select 'Other' if your Branch is not listedPlease selectAucklandAlexandraChristchurchDunedinHamiltonInvercargillNew PlymouthPukekoheQueenstownTaurangaThamesWanakaWellingtonOtherBranch (Other)Contact Name[*]Contact Mobile or Landline Number[*]// VEHICLE DETAILSMake[*]Select 'Other' if your Make is not listedPlease selectAlfa RomeoAudiAustinBentleyBMWChevroletChryslerCitroenDaewooDAFDaihatsuDaimlerFiatFordFreightlinerFusoGreat WallHinoHoldenHondaHyundaiIsuzuIvecoJaguarJeep KenworthKiaLadaLandroverLexusMackMANMazdaMercedes-BenzMGMitsubishiMorrisNissanOpelPeugeotPontiacPorscheProtonRenaultRolls-RoyceRoverSaabScaniaSeatSkodaSsangYongSubaruSuzukiToyotaTriumphUDVolkswagenVolvoWestern StarOtherMake (Other)[*]Model[*]Year[*]Select 'Other' if your Year is not listedPlease select2026202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990OtherYear (Other)[*]Door Type[*]Please select2-Door3-Door4-Door5-DoorBody Style[*]Select 'Other' if your Body Style is not listedPlease select4x4ConvertibleCoupéHatchbackLiftbackPeople-mover / MPVSedan / SaloonSUVTruckUtility / UteVan / MinivanWagon / Station WagonOtherBody Style (Other)[*]Number Plate[*]Work Required[*]Select 'Other' if your Work Required is not listedPlease selectFront Windscreen RepairFront Windscreen ReplacementRear Windscreen ReplacementSide / Door Glass ReplacementOtherWork Required (Other)[*]// FRONT WINDSCREEN FEATURE(S)Rain sensorCamera (Lane change warning system)Heated wiper systemWindscreen antenna (Radio and/or GPS)Check all that apply aboveI have ensured that the information I have supplied in the front windscreen features section is accurate// REAR WINDSCREEN FEATURE(S)Privacy tintedCheck all that apply aboveI have ensured that the information I have supplied in the rear windscreen features section is accuratePhone Number[*]// SIDE / DOOR GLASS PART(S)Driver's Side ¼ Glass in FrontPassenger's Side ¼ Glass in FrontDriver's Side Front Door GlassPassenger's Side Front Door GlassDriver's Side Rear Door GlassPassenger's Side Rear Door GlassDriver's Side ¼ Glass in Rear DoorPassenger's Side ¼ Glass in Rear DoorDriver's Side ¼ Glass in BodyPassenger's Side ¼ Glass in BodyCheck all that apply above// IMAGE UPLOADUpload an image of the damageMaximum filesize of 10 MB// COMMENTS / INFORMATIONSEND JOB REQUEST
