Shop Name Shop Phone Shop Owner Shop Fax Shop Email Shop Address Business Structure Type? Select Type Individual Corporation S Corporation LLC Operating as a DBA Yes No Tax ID What is the name of the parent company? (if DBA) Is the Tax ID above a SSN? Yes No Check the services your shop offers. Windshield Repair Windshield Replacement In Shop Service Recalibrations Primary Service Locations Mobile Service Range Do you have a Safelite account? Yes No Is this your preferred shop? Yes No Shop ID Do you have a Lynx account? Yes No Parent ID Lynx Username Safelite Username Lynx Password Safelite Password Do you bill insurance jobs? Yes No Name Phone Number Email Address Fax Submit Shop Name Shop Owner Shop Email Shop Phone Shop Fax Shop Address Business Structure Type? Select Type Individual Corporation S Corporation LLC Tax ID Is the Tax ID above a SSN? Yes No Operating as a DBA Yes No What is the name of the parent company? (if DBA) Check the services your shop offers. Windshield Repair Windshield Replacement In Shop Service Recalibrations Primary Service Locations Mobile Service Range Do you have a Safelite account? Yes No Shop ID Parent ID Safelite Username Safelite Password Is this your preferred shop? Yes No Do you have a Lynx account? Yes No Lynx Username Lynx Password Do you direct bill insurance jobs? Yes No Name Address Email Phone Number Fax Submit
