Schedule Glass Service Appointment

Glass Repair Request Form

Fill out the form below to schedule your appointment. Please give us as much information as possible so we can be as prepared as possible when you stop in. Also, select whether you would like to take advantage of our complimentary pick-up and drop-off service and courtesy rides.

Please allow at least 24 hours before your requested appointment.

First Name*

Last Name*

Address*

City*

State*Select OneAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonDistrict of ColumbiaWest VirginiaWisconsinWyoming

Phone (Daytime)*

Phone (Evening)*

Which location would you like to visit?* Select OneHam LakeFridleyBrooklyn Park

Who to Bill* Select OneBill MeBill My Insurance Company

Automobile Information:

Year*

Make*

Model*

Type* Select One2 door coupe4 door sedanHatchbackConvertibleStation WagonExtended CabCrew CabMini VanExtended Van

Type of glass needed* Select OneWindshieldBack GlassHatchbackConvertibleStation WagonStandard CabExtended CabCrew CabMini VanExtended Van

Other

Windshield options* NoneHeatedHeads up displayRain sensorAntennaDon't know

Tint Options* NoneBlue tint / Blue shade bandBronze tint / Blue shade bandBronze tint / Bronze shade bandBronze tint / Green shade bandDon't knowGreen tint / Blue shade bandGreen tint / green shade bandPrivacy Tint (tempered glass only)

Automobile Insurance Information

Insurance Company*

Policy Number

Agent's Name

Agent's Phone Number

Please specify any additional information or specific needs you might have regarding your appointment, including when you would like this work done.

Please confirm you are human and not a script.

*denotes required field