Repair Authorization - Xtreme Auto Collision Repair

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?*

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?

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*

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