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Company Information
Company NameCompany Phone #Company EmailTechnician NameCompany URL
Your company name here
your technician name here
your-url-here.com
Urethane Adhesive System DOW Xpress 30
Customer Information
Customer NameCustomer EmailInvoice #Insurance Claim #
customer name
customer-email@gmail 9945547900444
Auto Glass Replacement Inspection
Vehicle Information 2006 BMW Z4
Vehicle Mileage - 77501Vehicle License Plate
VIN #
Auto Glass Replacement Inspection
XXXXX
XXXXXXXX
XXXXX
XXXXXXXX
ADAS Systems and Sensors
Adaptive Cruise ControlHeads Up DisplayAntennaAuto ParkingForward Collision AlertHeated
Lane Departure CameraNight VisionRain SensorPedestrian Auto Emergency BrakingLane Keep Assist CameraNo Sensors
Vehicle Pre-inspection
Paint Body
Paint body damagedDentedNo Visible Damage
Rust CorrosionScratched
Other: roof scratched
Auto Glass Replacement Inspection
Paint/Body damage Photo 1
Glass Moulding
Missing PartsScratchedNo Visible Damage
DentedPreviously ReplacedCracked WeatherizedOther: Cowl Damaged
Glass Moulding Photo 1 Glass Moulding Photo 2
Interior Dashboard
Interior/Dashboard Photo 1
Cracks TearsRust CorrosionNo Visible Damage
Missing PartsStained
Other: Scratched Seat
Auto Glass Replacement Inspection
Customer Accepts Pre-Inspection
START TIME NOVEMBER 13, 2019 08:27 AM SAFE DRIVE AWAY TIME NOVEMBER 13, 2019 10:15 AM
Vehicle Post-Inspection
Parts Replaced
Back GlassQuarter GlassVent GlassRegulator Motor
Door GlassRoof/SunroofWindshield
Auto Glass Replacement Inspection
New Glass Part - Bug/Dot # Photo
Urethane Adhesive System Lot # Photo
Weather Section
Temp 60℉Humidity 82%Zip Code 94559
Auto Glass Replacement Inspection
Post Installation Notes
Body DamageDamaged SensorsRust Corrosion
Damaged MouldingAnti-pinch reset and operationalNo Visible Damage
Recalibration – A.D.A.SNO recalibration required = Auto Glass part replaced does not include, A.D.A.S (Advanced Driver Assistance System).
Instructions & Disclosures
Customer InstructionsDo not drive vehicle until SAFE DRIVE AWAY TIME - please remove any masking tape within 24 hours of installation date/time - do not wash vehicle for first 24 hours from installation date/time.SAFE DRIVE AWAY TIME: NOVEMBER 13, 2019 10:15 AM
Auto Glass WarrantyAll replacements have a lifetime air and water leak guarantee. All Glass/installation defects must be reported within 48 hours of installation date. Replacement Auto Glass must be contacted and alerted of any damage cost before repair. Failure to contact Replacement Auto Glass may result in forfeit of warranty.
Recalibration DisclosureReplacement Auto Glass has informed customer of the required RECALIBRATION process/service of the vehicles A.D.A.S (Advanced Driver Assisted System). Customer assumes all liability and costs of RECALIBRATION of the A.D.A.S (Advanced Driver Assisted System). Owner of this vehicle, or representative of owner is in full comprehension of the potential consequences of operating this vehicle without a successfully completed RECALIBRATION of the vehicles A.D.A.S ( Advanced Driver Assisted System). Owner of this vehicle, or representative of owner assumes all risk of injury and risk of damages of property. Signature of this disclosure/inspection form by owner or representative of owner hereby releases and forever discharges Replacement Auto Glass, as well as its trustees, officers, agents, employees and subcontractors from any and all claims, demands and cause of action, of whatever kind of nature, either in law or equity, arising from or in any way connected with A.D.A.S (Advanced Driver Assisted System) failure before completing a successful RECALIBRATION process/service. Replacement Auto Glass recommends the vehicles manufacturer/dealership for the RECALIBRATION of the A.D.A.S (Advanced Driver Assisted System).
Auto Glass Replacement Inspection
Approved Repair Customer Signature
