Auth Form – One Stop Auto Body & Paint - Collision Repair Specialists

NAME

Address

Address Line 2

State / Province / Region

ZIP / Postal Code

Vehicle Year/Make/Model

Date of Loss

Insurance Carrier

Please Indicate Which Applies to You

Are you the Registered Owner?

Do you have the Original Insurance Check?

Communication

Phone

Consent

I hereby authorize the required repair work to be completed to my vehicle along with the necessary materials. I hereby grant ONE STOP AUTO BODY SHOP and its employees to operate the vehicle here as described on street, highway, or elsewhere for the purpose of testing and inspection. An express mechanic’s lien is hereby acknowledged on the above vehicle should the need occur, to secure the remaining balance.

Consent

No vehicle will be released until payment is made in full. Please be certain all payees (including lien holders) have endorsed the insurance check prior to the completion of repairs.

Consent

I understand that ONE STOP AUTO BODY SHOP final invoice for repairs of my vehicle may not match the insurance company’s estimate as to parts, labor or procedures used to repair my vehicle. I understand that parts prices are based upon recent Estimating Software: however prices may vary due to currency effecting a high quality repair, and that Chaney's Collision Centers labor changes are based on hourly time allowances as given in the Collision repair industry estimating software, and their experience, and may be more or less than the amount of actual time.

Consent

I understand that all ONE STOP AUTO BODY SHOP estimates are final invoices based upon flat rate hours, as is customary in the collision repair industry; not actual time spent on repairs. I understand that a flat rate hour unit of time given for a certain repair operation and that the actual time spent on a repair operation can vary greatly from the flat rate time given to a labor procedure depending on technician experience and equipment provided and/or training.

Consent

ONE STOP AUTO BODY SHOP is not responsible for any lost or stolen items and/or damage to vehicles resulting from fire, theft, chipped windshields that can crack, or any other causes beyond our control. Please remove any personal articles from your vehicle, as it may be necessary to have outside companies perform work on your vehicle.

Consent

I agree to pick up my vehicle within the 24 hours after ONE STOP has notified me that the repairs are completed or after my vehicle has been repaired. If I fail to comply, I will be responsible for any additional rental and/or storage fees generated by my delay. If I fail to pick up my vehicle within the thirty days of receiving the statutorily required notices, Chaney's Collision Centers may sell or dismantle my vehicle.

Consent

Storage charges will accrue three (3) days after notification of the completion of repairs. Failure to make payment within 20 days of notification of the completion will result in commencement of the auction process to satisfy the implied mechanic’s lien. In the event that an insurance company fails to provide an estimate or there is an inability to come to an agreed price for the cost of the initial estimate or supplement within 10 business days of the vehicle arriving at ONE STOP AUTO BODY SHOP, there will be storage fees of $150.00 per day beginning with the day the vehicle arrived at ONE STOP AUTO BODY SHOP.

Consent

Vehicles towed in or driven in, later deemed a total loss, or moved to another facility for any reason by the customer or Insurance Company may be subject to administrative, lot debris cleanup charges or estimate fees. Any labor, towing or lift inspection fees must be paid before vehicle leaves ONE STOP AUTO BODY SHOP. Prior written notice must be given if parts are to be returned or damaged by the customer.

Consent

I understand that ONE STOP AUTO BODY SHOP will need to extract data that is stored in the vehicle, including its event data recorder, prior to conducting any scanning or diagnostics operations, and that Chaney will access such data only for the limited purpose of conducting vehicle diagnostics and/or repairs.

Consent

I understand that most vehicles are equipped with Advanced Driver Assistance Systems which require recalibration and extensive road tests, up to 30 miles, per manufacturers’ specifications, to ensure systems are working properly after repair. These extensive recalibration tests include, but are not limited to, systems such as cruise controls, forward collision warnings, blind spot monitors, and camera views. I understand that my vehicle may be required to have one or more of these systems recalibrated and tested.

Consent

I understand that any person who, with intent to defraud or knowing that s/he is facilitating fraud against an insurer, submits an application, or files a claim for payment of a loss containing a false or deceptive statement is guilty of insurance fraud and is subject to criminal and civil penalties.

Rental Car Notice ( Please select one of the below required fields. )

Consent

No Rental Car Needed

Consent (Rental Car Needed)

There can be many unforeseen delays in the completion of your repairs, therefore, you may want to consider a lower cost per day rental car to insure you have enough and/or additional rental days available while your vehicle is being repaired. We can only estimate a target completion date. In many cases, you can double the amount of rental days simply by choosing a lower cost vehicle per day. An accident can be an inconvenience, and when your rental coverage runs out it does not mean your vehicle should be complete. It is your responsibility to verify your rental car coverage and choose the appropriate rental coverage from your insurance company. Chaney's Collision Centers will not participate with subsidizing any rental charges in excess of that allowed by your insurance company and policy.

One Time Endorsement And Refund Notice

Consent

I hereby authorize Chaney's Collision Centers to endorse on my behalf all insurance checks and/or drafts received for payment of repairs completed on my vehicle under this Repair Authorization whereon my signature would be required. I further authorize payor(s) to pay Chaney's Collision Centers directly and understand that any drafts, checks and/or monies received will be applied to the outstanding balance on my account. All insurance checks received for my repair will be deposited and posted to my customer account immediately upon receipt. In the event there are any reimbursements necessary, all monies must be received for the completed repairs and all drafts and/or checks will subject to a TEN-WORKING DAY hold to allow sufficient time for them to process and clear the banking institution. After the 10-Day Hold has expired and all the drafts and/or checks have cleared, a reimbursement check will be requested and issued within 72 hours. Only confirmable bank checks, debit cards, credit cards, and EFTs are accepted.

Assignment Of Rights And Directions To Pay Motor Vehicle Claim

Consent

We brought the above vehicle to Chaney's Collision Centers for repair following an accident on the date stated above. Chaney's Collision Centers has not been fully paid for making its repair and/or for other charges due from us, for various reasons. To induce Chaney's Collision Centers to defer and/or waive collecting from us the unpaid charges and/or to induce Chaney's Collision Centers to release our vehicle to us, we assign to Chaney's Collision Centers all of the rights we have whatsoever as to the damage to and repair of our vehicle. This includes our rights as to our insurance company and our policy and all rights as to third parties(and their insurers) who may be liable to us in any way in connection with repair of our vehicle and Chaney's Collision Centers’ costs and charges due from us. These costs and charges may relate, without limitation, to vehicle repair, storage, auto rental and/or diminished value, steering and emotional distress. Also assigned without limitation are our rights under the law for bad faith and violations of this state’s Consumer Protection Act, Insurance Fair Conduct Act and Administrative Codes. Without limitation Chaney's Collision Centers may, under this assignment, exercise any and all rights and remedies and take any and all legal or other actions to enforce and collect on the rights here assigned to Chaney's Collision Centers. This assignment does not contemplate, and is not an assignment of, any personal injury claims assignors or other parties may have. This assignment is made of our free and voluntary act without compulsion. Chaney's Collision Centers personnel have explained this agreement and have given us time for questions and answers. A credit card surcharge of 3.5% will apply to all credit card payments. Alternatively, you may wish to pay by cash or debit, which will not incur a surcharge.

Owner/Assignor(s) Name*

Date

I consent to receive SMS/MMS messages from One Stop Collision Repair regarding services, appointments, and promotions. Message and data rates may apply.