Steering Incident Report

Person Submitting the Report

Grievance Reporter Name Grievance Company Name
Address City
State Zip
Phone E-mail
Are you a member of the MGDA? a copy of this report will be sent to the e-mail address supplied here

 

Auto Glass Company Information

 Same as Reporter?

Auto Glass Company Involved  
Address City
State Zip
Phone Primary Contact
Is this company a MGDA member?  

 

Consumer Information

 Same as Reporter?

Name of Consumer Involved  
Address City
State Zip
Phone E-mail

 

Insurance Company Information

Name of Insurance Company  
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 in as much detail as possible:

Date of Incident Approximate time of day
Claim/Job number (if applicable)
May MGDA 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 conversations?  Yes No

Please explain in detail what occured: