Authorization Form

Name

Email

Phone number

Year, Make and Model

Vehicle Identification number (VIN)

Insurance Company

Claim number (if applicable)

Agreed upon drop off date

Comments or Questions(optional)

By submitting my contact information along with my vehicle identification and insurance claim number (if applicable), I hereby authorize NW Collision Services to repair said vehicle. Upon completion of repairs, I authorize NW Collision Services to bill and receive payment from the insurance company handling my claim.

Furthermore, I hereby grant special Power of Attorney to NW Collision Services to endorse any insurance checks for this repair on my behalf. I understand that any deductible must be paid in full either by cash, credit / debit card, cashier’s check or insurance check before the vehicle will be released. *Personal checks with proper identification may be allowed up to $1000.00. Any other forms of payment (e.g. direct payment of payment (e.g. direct payment from the insurance) must be pre-approved prior to delivery of the vehicle.

In the event that legal action becomes necessary to enforce this contract, I further agree to pay reasonable attorney’s fees and court costs incurred. I understand that NW Collision Services is not responsible for loss or damage to the above-mentioned vehicle or the loss of articles left in the vehicle caused by fire, theft or any other causes beyond our control. And I further understand this company is not responsible for any delays caused by the unavailability of parts, back orders, insurance approvals, or quality assurance.