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Lancaster Glass
Schedule an Appointment |
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Please complete all applicable fields,
incomplete fields will delay your appointment. |
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 SERVICE
INFORMATION |
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Type of Service |
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Preferred Date |
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Preferred Time |
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AM (9:00 - Noon) |
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PM (Noon - 5:30) |
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Location |
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Lancaster Glass - O'Fallon |
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Home |
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Other
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Insurance Company |
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Agent Name |
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Agent Address |
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Agent City |
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Agent State |
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Agent Zip |
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Did you receive a
Quote from LGI* |
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No (Please continue to next section) |
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Yes - Please provide Quote # |
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Quote #
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*If you entered a quote
number from LGI
you may send the request now, if you do not have
a quote number please continue to the next section
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CONTACT
INFORMATION |
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Your Name |
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Address |
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City |
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State |
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Zip |
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E-mail |
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Phone (Day) |
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Phone (Night) |
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Phone (Cell) |
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Phone (Fax) |
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AUTO
GLASS INFORMATION |
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*Auto Glass Options
(Check all that apply) |
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Driver Side Glass |
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Passenger Side Glass |
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Misc Glass |
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Front Door |
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Front Door |
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Backglass |
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Front Vent |
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Front Vent |
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Rear Cargo Door |
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Rear Door |
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Rear Door |
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Slider |
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Rear Vent |
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Rear Vent |
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Sunroof |
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Side Quarter |
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Side Quarter |
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Moon Roof |
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Mirror |
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Mirror |
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Auto Glass Features
(Check all that apply) |
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Antenna in Windshield |
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Antenna in Backglass |
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Heated Windshield/Mirrors |
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Rear Defroster |
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Heads Up Display |
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Tinted Windshield |
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Upper Shade Band |
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Vehicle
Information |
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Year |
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Make |
(Ford, Toyota) |
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Model |
(Taurus, Camry) |
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HOME
GLASS INFORMATION |
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Please describe the glass product you
require so that we can better understand your need.
(Door, Window, Shape, Size, Bevel, Thickness, etc.) |
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I understand this is a
request to schedule an appointment and agree that no service of any kind
is bound by submitting information to Lancaster Glass, Inc. until
contacted by Lancaster Glass, Inc. with confirmation of the appointment.
I further understand that changes may occur in pricing and availability,
Lancaster Glass, Inc.
reserves
the right without prior notice to discontinue or change specifications
and prices on products and services quoted without incurring any
obligation.
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