IGA Grievance Registration Form

Please complete this auto glass steering report. This report will be used to collect information as it relates to auto glass repair and replacement. The data we are trying to capture relates to several issues, restricted access to the consumer, diminished vehicle value caused by the use of aftermarket parts and the insured's concerns having to pay the difference between OE and aftermarket parts. The report is completely confidential and will not be used publicly without your knowledge. Questions or concerns may be forwarded to 315-706-9172.

Grievance Registration Form:

Required Fields

Person Submitting Report
Grievance Reporter Name:		Grievance Company Name:
Address:		City:
State:		Zip Code:
Phone:		Email:
Are you a member of the IGA?	Yes No	A copy of this report will be sent to the email address supplied here.

Auto Glass Company Information Check this box if same as reporter
Auto Glass Company Involved:
Address:		City:
State:		Zip Code:
Phone:		Primary Contact:
Is this company an IGA member?	Yes No

Consumer Information Check this box if same as reporter
Name of consumer involved:
Address:		City:
State:		Zip Code:
Phone:		Email:

Insurance Company Information
Name of insurance company involved:
City:		State:
Phone:		Primary Contact:

Third Party (Claims) Administrator Information (if applicable)
Name of TPA involved:
City:		State:
Phone:		Primary Contact:

Please record your grievance below using as much detail as possible:

Date of Incident:

Approximate time of day:

Claim/Job Number (if applicable):

Glass Shop Job/Work Order Number (if applicable):

Have you filed a report with your State Insurance Commissioner? (Required) Yes No

May IGA follow up with you for further information? Yes No

May we share this information with legislators? Yes No

Was an audio recording made of any phone converstions? Yes No

Please explain in detail what occurred:

Was the issue resolved?

I agree that the information provided in this report is accurate to the best of my knowledge and
I agree to the terms and conditions for the use of the information I provide as explained at the top of this page.