Open an account

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Open an account

Open an account

Thank you for your interest in opening an account with Autoglass® Specials. In order to set-up the account, please could you complete the account application details below. Once you have submitted your application, we will contact you within 5 working days to confirm the account opening.

Terms and conditions

To download and view a copy of the Autoglass® Specials account application terms and conditons please click here (PDF file - 41KB).

If you don't have Adobe Reader you can download it here.

Company information

Company Name*

Address line 1*

Address line 2

Address line 3

Town/city*

County

Postcode*

Telephone*

Fax no*

Trading Status*

Company No. (or write 'n/a' if not applicable)*

Main fleet contact

Name*

Job title*

Telephone*

Email*

Type of business*

Fleet profile

No. of cars

No. of LCVs

No. of HGVs

No. of coaches

No. of buses

No. of plant and agriculture

Misc

Account Payable contact

Name*

Job title*

Telephone*

E-Mail*

Glass insurance cover

Glass insurance cover*

Name of Insurance company

Address line 1

Address line 2

Address line 3

Town/City

County

Postcode

Broker Details

Policy Type

Policy Number format

Excess £

Limit £

Limit Excess Inc

Expiry Date DD/MM/YYYY

Policy Code

Account Rules

Credit Limit Request

Terms and conditions

I confirm I have read the terms and conditions*

Don't fill this field!

Belron UK Limited t/a Autoglass® is registered in England and Wales. Number: 00494648.
Registered Office: 1 Priory Business Park, Cardington, Bedford, Bedfordshire MK44 3US.
© Copyright 2018 Belron UK Limited. All rights reserved.