Fields marked with * are required fields. Step 1 - Personal Contact InformationName* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email Enter Email Confirm Email By providing your email address, you agree to receive claim documents electronically.Step 2 - Vehicle InformationVehicle Identification Number (VIN)*Vehicle Year*Vehicle Make*Example: Mercedes, Porsche, Toyota, Chevrolet, Honda, etc.Vehicle Model*Example: Prius, C Class, Boxter, Impala, Accord, etc.Date Product Purchased Dealership Name*Step 4 - Claim Description InformationDate damage was noticed* Describe, the damage to the windshield in detail (i.e. chip, star, crack, size, etc.) and how the damage was sustained:*Describe the area(s) of damage to the windshield (see Windshield Damage Zones image below)*(please be as specific as possible)Special handling instructions (i.e. vehicle is at dealership, located in gated community, etc.)Step 5 - Acceptance and SubmissionPlease 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. Initials of Acceptance*PhoneThis field is for validation purposes and should be left unchanged.