Lynx 	Safelite 
 
 
 
 
 
 
 
 
*Date of Loss (mo/dy/yr):       	*Your Invoice #:      
*VIN:      
*Year		    
*Make		     
*Model		     
*Body Style	     
Prefix	Part Number	Color	List Price	Discount	Net Amount	
    	     	    	$     	     	$     	
    	     	    	$     	     	$     	
    	     	    	$     	     	$     	
    	     	    	$     	     	$     	
				Subtotal:	$     	
Total Cost of Repair:          
Kit:		     
Labor:		     
Deductible:	     
Tax:		     
TOTAL:	     
Insurance Company	
Parent ID (for Safelite)
*Shop Name:      
Contact:      
Phone:      
Fax:      
 
 Chip 1:       Chip 2:       Chip 3:       Chip 4:      

Windshield Repairs:

By forwarding this invoice to Data Tranz, we authorize Data Tranz LLC to electronically file this invoice with Lynx/Safelite on our behalf. We agree to hold Data Tranz LLC harmless in the event of a disagreement or error.  Data Tranz is not affiliated with Lynx/Safelite Services, and is not responsible in any way for Lynx /Safelite policies or pricing.  We agree to pay Data Tranz LLC their published service fee.  We understand the liability of Data Tranz LLC is limited to their service fee.

NAGS PARTS
Glass, Hardware, Molding

NOTE: If you are using a Premium, Dealer, OEM, or Non-Nags Part, call Lynx for prior approval.

*Lynx/Safelite Dispatch Number:

PAPER EDI

* Items are Mandatory   

           Vehicle Information:
(as shown on Lynx Job Assignment)

Fax to: 1-800-316-5829
Please make copies of this form as needed.