Binswanger

Schedule Service

About Your Vehicle

*Year:
*Make (ie; Ford, Saab, Toyota, etc.):
*Model (ie; Escort, 900S, Celica, etc.):

*Part Required
(You may choose as many parts as needed)

Windshield	Windshield Repair
Driver's Front Door	Passenger's Front Door
Driver Front Door Vent	Passenger Front Door Vent
Driver Side Rear Door	Passenger Side Rear Door
Driver Side Rear Door Vent	Passenger Side Rear Door Vent
Driver Side Quarter	Passenger Side Quarter
Backglass	Other

Options

Many times the part your vehicle needs varies with vehicle "options." Following is a list of vehicle options which could affect the part you need. Please select any which apply.

Antenna in windshield	Rear Defroster	Privacy Glass
Heads Up Display	Vinyl Roof	Hatchback
Heated Windshield	Sliding/Moveable	Sedan
Sunroof	Rear Wiper	Extended Cab (truck)
Overhead Console	Antenna in Backglass	Crew Cab (truck)
Convertible	Other Options

*Number of Doors

What color tinting is the glass in your vehicle? (You can check this by holding a piece of white paper up behind an open door window. Nearly all vehicles have tinted glass today - Clear glass is usually MORE expensive)

If you selected "windshield" as a part you would like installed, is there a shaded band (a darker area of color, not black) across the top?

Method of Payment

Binswanger Glass will directly bill your insurance company or agency. Leave the hassle of collecting to us - that's what we are trained to do. For deductibles or payment in full, you may use cash, check or credit card.

Bill my insurance company/agency

Insurance Company

Insurance Agency

I don't have glass coverage, bill me at time of installation

Note: If you are not certain if you have coverage, select "Bill my insurance agency" and provide your agent's name. We will call to verify coverage.

Your Information

*Your Name:
Your Home Address:
Your City:
*Your State:
*Your Zip Code:
*Your e-mail Address:
*Home Phone:
*Work Phone:
*Preferred Date of Installation:

Location of Installation:

Home
The Binswanger store nearest to me
Other (enter address)

Would you prefer a confirmation by:

Home Phone
Work Phone
E-Mail

How did you find out about Binswanger Glass on the internet? (you can choose as many as apply by holding the Ctrl key while selecting with the left mouse button)

Comments?

*=Required

Thank you for choosing Binswanger Glass for your service. You should have a response in less than 24 hours.