Windshield Medic - Where windshield repair is FREE to you!

If you are in the Denver, Colorado area and are in need of a windshield repair, you can use this form to get the jump on your insurance approval. With the following information, we can pre-approve your FREE repair. You can also call us with this information for pre-approval. Once approved, we will call you for an appointment.

When this page starts with
"https" (note the "s") this
page is secure

All information that you provide here is for internal use only and is not shared with any persons or companies that are not involved with completing your repair.

REQUIRED FIELDS *

About You

Email Address

First Name

Last Name

Contact Phone Number

Alternate Contact Phone Number

Address of repair to be performed

Suite, unit or apartment number

City

ZIP code

Best proposed time for repair:

Mobile Services Hours
Monday - Friday: 9am to 8pm
Saturday: 10am to 5pm
Sunday: 1pm to 5pm

Special arrangements can be made

   Select earliest time

   1 hour window
   2 hour window
   4 hour window
   All day

Best proposed day for the repair

About Your Vehicle

Year of Vehicle

Make of Vehicle

Model of Vehicle

Vehicle Identification Number (VIN)

Your VIN can be found on the lower drivers side area as viewed through your windshield from the outside. It can also be found on your registration and on most insurance cards.

License Plate Number

License Plate State

Insurance Carrier

Insurance Policy Number

Insurance Carrier's Phone Number

About The Damage

Customer Type

When did this damage occur

What type of Repair?

What type of Repair (if second repair)?

What type of Repair (if third repair)?

Comments:
No comments today, thank you!

If you have already received a claim number from your insurance carrier, enter it here:

ALREADY HAVE A CLAIM NUMBER ?

By clicking the "Send Request" button below, you are stating that you have authority to authorize us to contact your insurance company as stated above about this claim and you are authorizing us to do so.

All information that you provide here is for internal use only and is not shared with any persons or companies that are not involved with completing your repair.