Repair Authorization

Customer Information

Name*

Today's Date*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Cell Phone*

Alternate Phone

Email*

Preferred Method of Contact*

Text
Email
Phone Call

Check All That Apply

How did you hear about Xtreme Auto?*

Post Repair Xtreme Wash Service*

We are happy to offer a discounted rate for our Xtreme Wash to our customers to take the repair process a step further (normally $75 value): Sedans: $25 SUVs: $35 Pickups: $45

Yes, please perform Xtreme Wash Service
No, we would like to opt out of Xtreme Wash Service

Are you interested in detailing services?*

Yes, I am interested in detailing services
No, I am not interested in detailing services

Additional Detailing Servies*

Please provide additional details about each detailing service you have selected:

Vehicle Information

Vehicle Year*

Vehicle Make*

Vehicle Model*

V.I.N.

Are You Going Through Insurance?*

Yes
No

Insurance Company*

Insurance Phone Number*

Adjuster:*

Claim Number*

Check received from the Insurance Company?*

Yes
No
Getting Mailed

What amount is the Insurance Check for?*

Details of sent check:*

When was it mailed out? Where is it being mailed to? To whom is the check being mailed?

Do you know your deductible amount?*

Yes
No
N/A

What is your deductible amount?

Rental Car?

Yes
No

What is the rental car company you are using?

Pre and Post-Repair Diagnostic Scan

Pre and Post-Repair Diagnostic Scan Authorization

This diagnostic work authorization form grants Xtreme Auto Collision permission to perform a pre and post-repair diagnostic scan on your vehicle as part of the repair process. By accepting this procedure, you acknowledge the repair shop will not be held liable for problems with the vehicle that cannot be detected without proper diagnostic scans.

Pre Repair Diagnostic Scan: This is a complete health check of your vehicle and provides the repair shop (and insurance company, if applicable) a complete report on the number of computer modules on board, as well as any diagnostic trouble codes (DTC's) that could indicate pre-accident and/or accident related damage. This essential step eliminates the unnecessary delays waiting for parts and/or additional insurance authorization, and identifies issues with the vehicle that could be missed without a pre repair diagnostic scan.

Post Repair Diagnostic Scan: This step ensures that all systems on your vehicle are in proper working order prior to delivery. It is important to note that the majority of DTC's do not result in a malfunction indicator lamp (dashboard light). Failure to perform a post-repair scan by trained professionals with factory scanning tools significantly increases the risk that your vehicle may be returned with malfunctioning, or inoperable, safety and convenience systems. A post-repair diagnostic scan is the single best way to ensure that your vehicle is returned to pre-incident condition.

Data Privacy:

In the process of performing a diagnostic scan, Xtreme Auto Collision will collect important historical vehicle data, including in some cases, the date, time, and mileage of when a DTC was created. This information is helpful in understanding if a problem is accident related or pre-existing. It is possible this information will be shared with your insurance company. Your acceptance of this procedure grants Xtreme Auto Collision permission to share this information with others, including your insurance company. No personally identifiable information is collected during the pre or post-repair scan.

Disclaimers:

Diagnosing vehicles has limitations. In some cases, modified vehicles may give false DTC's. Xtreme Auto Collision and its employees cannot be responsible for omission or errors caused by the information provided, or not provided, by the customer.
All work performed by Xtreme Auto Collision will be in accordance with Original Equipment Manufacturer (OEM) specifications and defaults. This includes, but is not limited to, any repairs, calibrations, integrations, programming and set points as indicated by the OEM by way of their designated sources of such information. Xtreme Auto Collision is not responsible for any damage that results from, or to, aftermarket parts, or modifications from any OEM factory specifications.
Variations between vehicles, according to the make, model, and trim level, may limit the information captured during a pre or post-repair diagnostic scan.
Depending on the condition of the vehicle, and the extent of the damage, and other factors outside the control of Xtreme Auto Collision, a factory scan tool many not see every system on the vehicle being scanned.
Xtreme Auto Collision is not responsible for any changes made to the vehicle after the vehicle leaves the shop.

Pre and Post-Repair Diagnostic Scan*

While Xtreme Auto Collision recommends a pre and post-repair scan on every vehicle, it is especially important to perform these functions on newer, highly optioned, heavily damaged vehicles. Failure to do so significantly increases the risk to the vehicle owner and the occupants. Please select an option below after reading this information.

Yes. I agree and accept responsibility for the pre ($110) and post-repair ($125) diagnostic scans being performed on my vehicle. I understand, in some instances, insurance coverage may not be determined until after the diagnostic scans are performed.
No. I decline having the pre and post-repair diagnostic scans performed on my vehicle, though they were recommended by Xtreme Auto Collision and the need for them was explained to me. I understand Xtreme Auto Collision will not be held liable for any hidden or future damage that could not be detected during the repair process as a result of not having performed a pre/post repair scan. I also understand certain systems may not function correctly, or at all, following the repair, and it would be impossible to detect issues with those systems without a post-repair diagnostic scan. I release Xtreme Auto Collision from all liability for any pre-accident issues, hidden damage, or post-repair malfunctions that would have been discovered had I consented to having the diagnostics performed.

Repair Authorization*

Select one

I hereby authorize Xtreme Auto to make repairs to the vehicle referenced above. I acknowledge that I have received an initial estimate from Xtreme Auto. I understand there may be additional charges to the estimate quoted, due to hidden damage to my vehicle found during the repair process. I understand that Xtreme Auto will contact me with additional information in regard to any cost above the estimate quoted before the additional work begins. I authorize Xtreme Auto to inspect and coordinate the full repair process. I understand this may include enlisting other companies to assist in completion of repair work. I acknowledge and agree that I am responsible for the total amount(s) due upon the completion of repairs including an initial deposit of 50% prior to or on the date of drop-off and any remaining balance at the time of pickup and delivery of the vehicle referenced above.
I hereby authorize Xtreme Auto to make repairs to the vehicle referenced above. I authorize Xtreme Auto to inspect and coordinate the full repair process with the insurance company responsible for payment. I understand this may include enlisting other companies to assist in completion of repair work. I hereby authorize the insurance company listed above to issue payment directly to Xtreme Auto for the repairs of my vehicle. I further authorize Xtreme Auto to act as power of attorney to endorse all checks to satisfy the cost of repairs. I acknowledge I am responsible for any deductible, co-insurance payment or other charges not paid by the insurance company prior to or on the date of drop off. I also agree that those amounts, and any additional charges not paid by the insurance company are due and payable upon completion of repairs and delivery of the vehicle referenced above.

Do you want your old parts?*

Yes
No

Signature*

Use your mouse or finger to sign