
REPAIR AUTHORIZATION
Name _________________________________________________
Address _________________________________________________
City, State, Zip _________________________________________________
Home Phone _________________ Work Phone ___________________
Cell Phone _________________
Year/Make/Model ___________________________
Insurance Company ___________________________
Claim No. ___________________________
• WORK AUTHORIZATION
I hereby authorize this repair shop to make necessary repairs in accordance with its written
estimate or that written by the insurance company referenced above. The estimate of repairs
includes parts, labor and diagnosis. Parts prices quoted are current, but are subject to change
upon notice by manufacturer. If upon further inspection additional parts and/or repairs are
needed, I will be contacted for authorization.
I hereby authorize employees of the repair shop to operate my vehicle for the purpose of testing,
inspection or delivery.
I understand that it is my responsibility to remove personal belongings from my vehicle prior to
repairs, and I will not hold the repair shop or its employees responsible for loss or damage to the
vehicle or articles of personal property left in the vehicle, regardless of value, in case of fire,
theft, accident or any other cause.
• PAYMENT AUTHORIZATION
I hereby authorize any and all insurance payments and supplements for repairs made to my
vehicle to be paid directly to the repair shop. I do hereby appoint the repair shop as my attorney
in fact to accept on my behalf any and all checks, drafts or bills of exchange and to endorse all
such checks, drafts or bills for deposit as credit on my account for repairs on my vehicle. I
understand that I am responsible for any deductible, adjustment for depreciation and/or
betterment amounts or failure of my insurance company to pay other labor, part or material costs
necessary to restore my vehicle to its pre-accident condition as required by state law. Unless
other arrangements are made, the total amount of the repair charges must be paid in full before
the vehicle will be released for delivery.
To secure payment in the amount of repairs hereto, an express mechanic’s lien is acknowledged,
and I further agree to pay reasonable attorney’s fees and court costs in the event that legal action
is necessary to enforce this contract.
______________________________ _________________________
Signature of Vehicle Owner Date