Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.* Repair or Replacement? *Chip Repair(s) on windshieldLong Windshield Crack RepairInstallation/Replacement Glass(Installation/Replacement Glass please complete this form) For *windshield repairs* please phone us at the shop ( Mon-Fri 8-4 ) to arrange a time for Chip Repairs or Long Windshield Crack Repairs (780)488-2255 Contact Crackmasters for windshield repair (after hours glass repairs please complete this form) * Name *FirstLast* Phone *cell phone if possible* Email *Address Address Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryYour Address* Year *The year the vehicle was made* Make *The make of your vehicle (ie: Ford, Dodge, Honda, etc)* Model *The model of your vehicle (F-150, Journey, Civic…)* Body Style *SUV or VAN2 door Coupe4 door Sedan4dr Crew CAB (truck w/full-size rear doors)4dr Super CAB (truck w/smaller rear doors)2 door Standard CAB4 door Hatchback / STN Wagon2 door HatchbackConvertible2 door Hardtop (classic cars)other* Glass location on vehicle *Windshield |Front/Left (driver-side) door |Front/Right (passenger-side) door |Standard Sunroof |Rear/Left (driver-side) door |Rear/Right (passenger-side) door |Deflector glass (between windshield and roof glass) |Roof Glass Front (slides open) |Roof Glass Rear (fixed does not open) |Quarter Glass Left (behind the doors) |Quarter Glass Right (behind the doors) |Vent glass on Right door (small glass/does not open) |Vent glass on Left door (small glass/does not open) |Back Window (PLS add notes below for Tint, Heat, Slider…)Back window with power-slider, manual-slider, stationary (does not open)? Tinted? non-Tinted, Heated? non-Heated? Please make note belowBrief description of damaged glass, location and/or glass properties (side of car, tint, heat, movable…)Auto glass notes: left or right side / tinted / opens / does not open / Front, middle, or back / heated* Windshield Options (Check all that apply) *NO: Self-dimming rear-view mirror (I manually flip the switch if there are bright lights behind me) |YES: Electrochromatic rear-view mirror (self dimming)YES: Heated (Fine Wire Heated or Heated Wiper Park Area)YES: Humidity / Condensation SensorYES: Rain SensorYES: Forward Collision AlertYES: Heads Up Display (info shines on windshield)YES: Lane Departure Warning System, or Lane Keep Assist, or Eyesight TechnologyYES: Adaptive Cruise ControlYES: Active Braking AssistYES: Road Sign AssistanceYES: (front) Pedestrian DetectionYES: Driver Attention Warning SystemYES: Antenna in windshieldDo not need a windshield (or has no features)If unsure please provide (serial number) VIN: xxxxxxxxxxxxxxxxxVINPLEASE provide (Serial Number) VIN to help find proper windshield with the vehicle featuresPreferred day to do workAny day (next available) orMonday |Tuesday |Wednesday |Thursday |Friday |Crackmasters 17544 105 Ave Edmonton AB is open Monday-Friday 8-5 pm Preferred time for vehicle drop-off08:00 am – 9:00 am ( 9 am to Noon appointment)12:00 pm – 1:00 pm ( 1 pm to 4 pm appointment)Morning or Afternoon would worktypically a 3-hour appointment; Monday – Friday either 9-Noon or 1-4 pmFleet Card name/number or Insurance Company name, Policy & Claim numberNot required ( good to have ) and required if you are going through Insurance / Fleet card* Would you like a pair of new BOSCH Clear Advantage Wiper Blades installed * YES, please! Add a pair of BOSCH windshield wipers (axiom New Shoes, New socks!) $30no new wipers ( I will risk scratching a new windshield with my old wipers) $0install new ones I’ll supply (and pay $15 service fee) $15BOSCH Clear Advantage Wiper Blades; with Beam design reduces exposed metal, resisting ice and snow build-up for all-weather windshield wiping. BOSCH Clear Advantage’s Graphite wiping edge reduces friction for a quiet + smooth wipe in all seasons.Would you like Aquapel (water repellent) Glass Treatment (lasts 6-9 months)YES, please! Apply Aquapel to my windshield: $20no Aquapel thank you: $0Aquapel Glass Treatment is a rain repellent that improves vision in the rain or wet snow, allowing you to see better and drive safer. Repels rain for improved vision | Makes it easier to clear ice, snow and even dirt/bugs | Reduces glare in the rain, especially at night | Helps reduce water marks and road salt buildup.Submit