Fillable Form DA 2073 VEHICLE GLASS REPAIR / REPLACEMENT LOSS NOTICE

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Form DA 2073 VEHICLE GLASS REPAIR / REPLACEMENT LOSS NOTICE

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The Form DA 2073 VEHICLE GLASS REPAIR / REPLACEMENT LOSS NOTICE form is 1 page long and contains:

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  • 6 check-boxes
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Country of origin: US
File type: PDF

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DA 2073
3/93
VEHICLE GLASS REPAIR / REPLACEMENT LOSS NOTICE
AGENCY’S NAME
ADDRESS
COMPLETE IF DIFFERENT FROM AGENCY NAME
VEHICLE OWNER’S NAME
ADDRESS
CONTACT PERSON’S NAME
PHONE NUMBER
DATE OF BREAKAGE
TIME
AM
PM
DATE REPORTED
WORK PHONE
HOME PHONE
REPORTED TO
PHONE NUMBER
LOCATION OF VEHICLE
LOCATION CODE
CHECK ONE
STATE VEHICLE OTHER
VEHICLE INFORMATION
YEAR
MAKE
MODEL
BODY STYLE
LIC. / EQUIPMENT NO.
VIN
DID BREAKAGE OCCUR YES
DUE TO ACCIDENT NO
MOTOR VEHICLE ACCIDENT YES
REPORT ATTACHED NO
GLASS DAMAGED
REPLACEMENT REPAIR
DESCRIBE HOW BREAKAGE OCCURED
DAMAGED AREA INSPECTED BY
PHONE NUMBER
DATE
IF WINDSHIELD, CHOOSE THE TYPE OF DAMAGE AND INDICATE LOCATION ON DIAGRAM
COMMENTS
SIGNATURE OF AGENCY REPRESENTATIVE
DATE
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Form DA 2073 VEHICLE GLASS REPAIR REPLACEMENT LOSS NOTICE

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Completed 21 January 2020

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