submit.glassclaim.com Open in urlscan Pro
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Form analysis
1 forms found in the DOM

POST ./Welcome.aspx

<form method="post" action="./Welcome.aspx" id="aspnetForm" novalidate="novalidate">
  <div class="aspNetHidden">
    <input type="hidden" name="__VIEWSTATE" id="__VIEWSTATE" value="/wEPDwULLTE0MjE2ODI2MTIPZBYCZg9kFgICCQ8VAQVGYWxzZWRkWJONm9sHsdz3L/kUR9ElRy3gvXo=">
  </div>
  <div class="aspNetHidden">
    <input type="hidden" name="__VIEWSTATEGENERATOR" id="__VIEWSTATEGENERATOR" value="0B4D1132">
  </div>
  <section id="primaryContent" class="container">
    <div class="modal fade" id="policyNumberModal" tabindex="-1" role="dialog" aria-labelledby="policyNumberModalLabel" aria-hidden="true">
      <div class="modal-dialog">
        <div class="modal-content">
          <div class="static-modal-header">
            <h1>Policy Number:</h1>
          </div>
          <div class="static-modal-body">
            <div class="row">
              <div class="col-xs-12">
                <p class="text-success">
                  <em id="policyText">Your policy number is displayed as three sections of digits on your policy declaration page. Please provide the numbers in the form field as shown below.</em>
                </p>
              </div>
            </div>
          </div>
          <div class="row">
            <div class="col-xs-12">
              <div class="form-group has-feedback">
                <label class="control-label"> Your Policy Number: 123456789 101 1 </label>
              </div>
            </div>
          </div>
        </div>
      </div>
    </div>
    <div class="content-group">
      <div class="row">
        <div class="col-xs-12 col-sm-7">
          <h2 id="pageTitle">Welcome to Private Client's glass claim center</h2>
          <p class="pageInstructions">Submitting a glass damage claim takes just a few minutes. We'll ask you some questions, verify your coverage, then schedule your service.</p>
        </div>
      </div>
      <div class="row">
        <div class="col-sm-7 col-xs-12">
          <div class="form-group has-feedback">
            <label class="control-label" for="PolicyNumber">Policy number</label>
            <input type="text" name="PolicyNumber" id="PolicyNumber" class="required form-control" data-bind="textInput: PolicyNumber" placeholder="" autofocus="" aria-required="true">
            <div>
              <em>
                <small id="PolicyHelperTextLink" data-bind="visible: ShowPolicyHelpertextLink" style="display: none;"><a id="PolicyHelperLink" href="#"></a></small>
                <small id="PolicyHelperText" data-bind="visible: ShowPolicyHelpertext" style="display: none;"></small>
              </em>
            </div>
          </div>
          <div class="form-group has-feedback zip-top">
            <label class="control-label" for="ZipTop">Policy ZIP</label>
            <input type="tel" name="ZipTop" id="ZipTop" class="required form-control" data-bind="textInput: Zip" maxlength="5" pattern="^\d{5}$" title="Please enter 5 digits" aria-required="true">
          </div>
          <div class="form-group has-feedback">
            <label class="control-label" for="PrimaryPhone">Best number to reach you</label>
            <input type="tel" name="PrimaryPhone" id="PrimaryPhone" class="required-phoneUS phoneUS form-control" maxlength="20" data-bind="textInput: PrimaryPhone" autocomplete="tel-national" placeholder="###-###-####">
          </div>
          <div class="form-group has-feedback">
            <label class="control-label" for="Extension">Ext.</label><span class="optional"> (Optional)</span>
            <input type="tel" name="Extension" id="Extension" class="form-control extensionFive" maxlength="5" data-bind="textInput: Extension" autocomplete="tel-extension">
          </div>
          <div id="lossdatediv" class="form-group has-feedback">
            <label class="control-label" for="LossDate">When did the damage occur?</label>
            <input type="text" name="LossDate" id="LossDate" class="required validDate pastDate lossMinDate form-control" placeholder="MM/DD/YYYY" data-bind="textInput: LossDate" aria-required="true">
            <span class="disclaimer" id="LossDateText" data-bind="visible:!isLossDateFieldReadOnly()">Not sure? If you don't know the exact date, give us your best estimate.</span>
          </div>
          <div class="form-group has-feedback">
            <label class="control-label" for="LossCause">How did the damage occur?</label>
            <select id="LossCause" name="LossCause" class="required form-control" data-bind="value: LossCause" aria-required="true">
              <option value="">Select an option</option>
              <option value="ROCK FROM ROAD - NO ONE AT FAULT">Rock from road</option>
              <option value="VANDALISM - PERSON UNKNOWN">Vandalism</option>
              <option value="ATTEMPTED THEFT OR THEFT">Attempted theft or theft</option>
              <option value="HAILSTORM">Hail storm</option>
              <option value="HURRICANE/STORM">Hurricane/Storm</option>
              <option value="WEATHER - EXTREME HEAT OR COLD">Other weather</option>
              <option value="RESULT OF COLLISION">Collision</option>
              <option value="OBJECT HIT GLASS">Object hit glass</option>
              <option value="OTHER">Other/Unknown</option>
            </select>
          </div>
          <div class="form-group has-feedback zip-bottom">
            <label class="control-label" for="Zip">Policy ZIP</label>
            <input type="tel" name="Zip" id="Zip" class="required form-control" data-bind="textInput: Zip" maxlength="5" pattern="^\d{5}$" title="Please enter 5 digits" aria-required="true">
          </div>
        </div>
      </div>
    </div>
    <same-device-modal params="display: isSameDevicePopup, savedQuoteCookieEntity: savedQuoteCookieEntity, accountName: accountName, selfServiceAccountName: selfServiceAccountName">
      <div class="modal fade" aria-hidden="true" role="dialog" id="sameDeviceModal" tabindex="-1" data-backdrop="static">
        <div class="modal-dialog modal-dialog-centered" role="document">
          <div class="modal-content">
            <h3>Welcome back, how may we help you?</h3>
            <p>It looks like you have started to file a claim for your <span data-bind="text: make"></span> <span data-bind="text: model"></span>.</p>
            <button type="button" class="btn btn-success" data-bind="click: finishClaim"> Finish existing claim </button>
            <div class="or-container">
              <hr>
              <span class="or">or</span>
            </div>
            <button type="button" class="btn btn-primary" data-bind="click: startNewClaim"> Start a new claim </button>
          </div>
        </div>
      </div>
    </same-device-modal>
  </section>
  <section id="pageNavigation" class="container-fluid">
    <div class="container">
      <div class="row">
        <div class="col-sm-7">
          <div style="float: right">
            <button name="navNext" id="navNext" type="button" class="btn btn-success" data-bind="click: doSubmit, enable: CanSubmit">Get started</button>
          </div>
        </div>
        <div class="col-sm-12 pull-left">
          <p class="disclaimer" id="needHelp"> Need help? Call (844) 690-1992 or <a href="/self-service/Bailout.aspx?c=help" tabindex="0">request that we call you.</a>
          </p>
        </div>
      </div>
    </div>
  </section>
</form>

Text Content

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Alert: Global glass shortages are impacting appointment availability


POLICY NUMBER:

Your policy number is displayed as three sections of digits on your policy
declaration page. Please provide the numbers in the form field as shown below.

Your Policy Number: 123456789 101 1


WELCOME TO PRIVATE CLIENT'S GLASS CLAIM CENTER

Submitting a glass damage claim takes just a few minutes. We'll ask you some
questions, verify your coverage, then schedule your service.

Policy number

Policy ZIP
Best number to reach you
Ext. (Optional)
When did the damage occur? Not sure? If you don't know the exact date, give us
your best estimate.
How did the damage occur? Select an option Rock from road Vandalism Attempted
theft or theft Hail storm Hurricane/Storm Other weather Collision Object hit
glass Other/Unknown
Policy ZIP


WELCOME BACK, HOW MAY WE HELP YOU?

It looks like you have started to file a claim for your .

Finish existing claim

--------------------------------------------------------------------------------

or
Start a new claim
Get started

Need help? Call (844) 690-1992 or request that we call you.

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