MAGI, LLC
200 Latta Brook Park
Horseheads, NY 14845
Tele 1-866-575-4747(GRIP)  Fax (607) 734-0011 www.autoglassprotection.com

“G.R.I.P.”
Glass Replacement Installation Protection Plan
DISTRIBUTOR APPLICATION FORM


Distributor Name
 CODE
Office Telephone
 Office Fax
Distributor Email:
  
Applicant Name:
 (First) (Last)
Telephone:
 
Mailing Address:
 
(City) (State) (Zip) (County)
E-Mail Address:
Requested Policy Period: 12 months 12:01 A.M. Eastern Standard
 

VEHICLE DESCRIPTION – COMPLETE ALL BOXES
Year
Make
Model
Body
Builder No
VIN NO.

Please check one:
$99.00 for personal vehicles
$199.00 for commercial vehicles
$299.00 for emergency vehicles


WE DO NOT COVER LOSSES TO AUTO GLASS DUE TO THE INSURED AUTO'S COLLISION WITH ANOTHER VEHICLE, STATIONARY OBJECT, OR THE INSURED AUTO'S

OVERTURN. AUTO GLASS FOUND TO HAVE DEFECTS SUCH AS CRACKS, HOLES, CHIPS, BREAKS, OR ANY OTHER GLASS IMPERFECTIONS IS NOT ELIGIBLE. WE DO NOT PROVIDE ANY MANDATORY AUTOMOBILE LIABILITY INSURANCE OR ANY PHYSICAL DAMAGE COVERAGE FOR THE VEHICLE EXCEPT GLASS. IF THIS INSURANCE IS

OBTAINED UNDER FRAUDULENT MEANS THEN WE ARE NOT BOUND TO PAY ANY CLAIM AND THE APPLICANT WILL FORGO ANY REFUND OF PREMIUM.


Applicant's Signature Date
Distributor's Signature Date
GRIP REV. 02/09      

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