Hertich Collision Centers Wayside Authorization Form
Greg
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5cba5ddc0a0e09a722688c6618fa6b70 Collision Centers
CUSTOMER INFORMATION
Name
Date
Address
Cell#
City
State
Zip
Home#
Email What is your preference for system generated updates on your vehicle?
Work# Text
Email
How can we exceed your expectations?
Any concerns since the accident? VEHICLE INFORMATION
Year CLAIM INFORMATION
Make
Who is paying for this repair? If insurance, do you have their estimate?
Yourself YES or NO
Model
Color
Your Insurance
Their Insurance
Did you receive payment from them?
Other YES or NO
Insurance Company
Claim #
Deductible Amount
WORK AUTHORIZATION I hereby authorize Wayside Body Shop to proceed with parts order, disassembly, and repair to the above noted vehicle. I agree that Wayside Body Shop is not responsible for any loss or damage to the vehicle or articles left in the vehicle in case of fire or theft beyond our control or for any delays caused by the unavailability of parts or shipping delays. I agree that there will be a 35% parts restocking fee if I cancel this repair. I hereby grant permission to Wayside Body Shop employee's to operate this vehicle for the purpose of inspection, road testing or transporting for work related to this loss.
TERMS I acknowledge that the initial estimate of repairs may change after disassembly with a closer analysis of the damage. I appoint Wayside Body Shop to represent and collect for any additional supplement repairs and payments from the insurance company. If there are any additional amounts that I will pay, I will be contacted by the shop for my authorization. An expressed mechanics lien is hereby acknowledged on the above vehicle to secure the total amount of repairs thereto, and I further agree to pay reasonable attorney's fees and court costs in the event legal action is necessary to enforce this agreement. Payment in full is expected upon completion of your repair and before vehicle will be released. Accepted methods of payment for repairs are Insurance Checks, Cashier's Checks, Cash, Money Orders, Debit and Credit Cards including MasterCard, Visa, and Discover.
POWER OF ATTORNEY
For consideration of the repairs made to the above vehicle, I hereby grant Wayside Body Shop power of attorney to sign or endorse any checks or drafts made payable to me and release thereto as settlement for repaired damages to this claim on my vehicle.
** PICKUP HOURS ARE MONDAY-FRIDAY 8AM-5PM ** WE DO NOT ACCEPT PERSONAL/BUSINESS CHECKS OR AMERICAN EXPRESS ** A CONVENIENCE FEE OF 3% WILL BE ADDED TO ALL CARD CHARGES EXCEEDING $1500.00
INITIAL INITIAL INITIAL
AUTHORIZED BY
DATE
PRINTED NAME
Wayside Body Shop 25691 Shore Highway, Denton, MD, 21629
Customer Authorization Form
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