Windshield Claim Form

The Online Windshield Claim Form is broken into 4 steps. Please Note: Any claim not completed will not be processed. Fields marked with * are required fields.

  • Step 1 - Personal Contact Information

  • By providing your email address, you agree to receive claim documents electronically.
  • Step 2 - Vehicle Information

  • Example: Mercedes, Porsche, Toyota, Chevrolet, Honda, etc.
  • Example: Prius, C Class, Boxter, Impala, Accord, etc.
  • Step 3 - Warranty Registration Information

    The prefix letter(s) and number are located at the top right corner of your Customer Registration Form.
  • Step 4 - Claim Description Information

    Please Note: All dates will be required in order to process any claim.
  • (please be as specific as possible)
  • WindshieldZones
  • Step 5 - Acceptance and Submission

    Please read the following statements carefully, as a claim will not be processed unless initials from the claimant have been provided.
  • Please type your initials to indicate: I am aware that PermaPlate Company LLC, Inc. relies on the information and statements above. I hereby certify that the above statements are complete and accurate to the best of my knowledge. Any fraudulent statements will result in invalidity of warranty.
  • This field is for validation purposes and should be left unchanged.