DTP/Work Authorization

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"*" indicates required fields

Name*

Address*

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

Phone*

Email*

Year/make/model of Vehicle*

Insurance Company*

Claim#*

I hereby authorize the repair work to be done along with the necessary material, and hereby grant the shop to operate the vehicle herein described on streets, highways, or elsewhere for the purpose of testing/inspecting. An express mechanics lien is hereby acknowledged on the above vehicle to secure the amount of repairs thereto. CarWorks Collision Repair Center is not responsible for the availability of parts, or delays in part shipments beyond their control, nor for the loss, or damage to the vehicle, or articles left in the vehicle in case of fire, theft, or any cause beyond our control.

I do hereby appoint the business to accept and sign on my behalf any, and all checks, drafts, or bills of exchange, and endorse all such checks, drafts, or bills of exchange for deposit to the business account for credit on my account for repairs on my vehicle which has been released and accepted.

I authorize the above listed insurance company to pay CarWorks Collision Repair Center directly on the claim number listed above. In the event the insurance, or the adjustment company inadvertently mails the settlement/supplement check to be in error, I hereby agree to notify the said shop immediately and agree to deliver such check to the repair facility within 48 hours of my receipt of such check.

I acknowledge that the shop will work with the insurance company directly on my claim, however if they are not able to get reasonable and timely resolution, I understand that I might have to assist with the claim.

I acknowledge the shop charges storage fees if the vehicle is not repairable and/or if I choose to remove the vehicle from the shop without repair completion. Storage in most cases is covered by the insurance companies, however if the customer decides to remove the vehicle from the shop, the storage might become the customer’s responsibility prior to the removal of the vehicle from the shop

By Typing Your Name Here You Are Authorizing Work on Your Vehicle*

Date*

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Insurance Company*

Claimant (not at fault)

Insured (at fault)

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Is the Vehicle Fully Insured ?*

Yes

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Preferred Appointment Date (Mon-Thurs)*

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Preferred Appointment Time*

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Attach Photos of Damage*

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Preferred Appointment Day & Time*

Untitled

Name

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