Pre-Payment Program Application

Complete the application below to apply for the Capital Auto Glass Pre-Payment Program. For questions, see our Q&A page or call us.

Personal Information

First Name

Middle Name

Last Name

Home Address

Phone

Text #

Business Information (if applicable)

Business Name

Contact Person

Position

Business Address

Business Phone

Business Text #

Business Email

Choose A Pre-Payment Plan (check one)

Platinum (20%) ($1,000 – $2,000) Gold (15%) ($500 – $999) Silver (10%) ($100 – $499)

How Much Do You Want To Fund?

How Do You Want To Fund? (check one)

Credit Card (additional non-refundable 3% fee for credit card usage) Check: Make check payable to Capital Auto Glass. Write "Pre-payment plan" on Memo. Cash: Cash payments are accepted exclusively in store. Do not send cash via mail.

Credit Card Information (if paying by card)

Credit Card Number

Name on Credit Card

CVC Code

Expiration Date

Billing Address

Signature (Please Print Name)

Date

⚠️ Please do not enter actual credit card details in this online form. For credit card payments, please visit us in person or call (916) 972-7772.

We are Approved Insurance Provider

Pre-Payment Application