Authorization Form

Repair Authorization

I authorize Re-Lux Collision to perform all necessary repairs on my vehicle and to endorse any insurance checks or payments on my behalf. I understand that all charges, including repairs, storage, and administrative fees, must be paid in full before the vehicle is released. Re-Lux Collision may also pursue payment directly from my insurance or liable third parties if needed. A 3% surcharge applies to credit card payments.

Name

⠀

Address

Vehicle Year/Make/Model

Date of Loss

Insurance Carrier

Please Indicate Which Applies to You

Are you the Registered Owner?

Yes No

Do you have the Original Insurance Check?

Yes No

Communication

Email Text Call

Phone

Authorization to Repair

Consent

I hereby authorize the required repair work to be completed to my vehicle along with the necessary materials. I hereby grant Re-Lux Collision 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 ensure that all payees, including lien holders, have endorsed the insurance check before the completion of repairs.

Consent

I understand that Re-Lux Collision’s 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 affecting a high-quality repair. Additionally, I acknowledge that Re-Lux Collision’s labor charges are based on hourly time allowances as provided 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 Re-Lux Collision estimates and final invoices are based upon flat rate hours as customary in the collision repair industry, not on actual time spent on repairs. I understand that a flat rate hour is a 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 for a labor procedure, depending on technician experience, equipment provided, and/or training.

Consent

Re-Lux Collision is not responsible for any lost or stolen items and/or damage to the vehicle resulting from fire, theft, chipped windshields that can crack, or any 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 24 hours after Re-Lux Collision 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 thirty days of receiving the statutorily required notices, Re-Lux Collision 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 the 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 Re-Lux Collision, there will be storage fees of $150.00 per day beginning with the day the vehicle arrived at Re-Lux Collision.

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 the vehicle leaves Re-Lux Collision. Prior written notice must be given if parts are to be returned or are damaged by the customer.

Consent

I understand that Re-Lux Collision 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 Re-Lux Collision 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 they are facilitating a 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 ensure 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 number 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 will be complete. It is your responsibility to verify your rental car coverage and choose the appropriate rental coverage from your insurance company. Re-Lux Collision will not participate in 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 Re-Lux Collision to endorse on my behalf all insurance checks and/or drafts received for payment of repairs completed on my vehicle under this Repair Authorization where my signature would be required. I further authorize payor(s) to pay Re-Lux Collision 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 that any reimbursements are necessary, all monies must be received for the completed repairs, and all drafts and/or checks will be 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 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 Direction to Pay Motor Vehicle Claim

Consent

We brought the above vehicle to Re-Lux Collision for repair following an accident on the date stated above. Re-Lux Collision has not been fully paid for making its repair and/or for other charges due from us, for various reasons. To induce Re-Lux Collision to defer and/or waive collecting from us the unpaid charges and/or to induce Re-Lux Collision to release our vehicle to us, we assign to Re-Lux Collision 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 the repair of our vehicle and Re-Lux Collision’s 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, Re-Lux Collision 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 hereby assigned to Re-Lux Collision. 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. Re-Lux Collision personnel have explained this agreement and have given us time for questions and answers. A credit card surcharge of 3% will apply to all credit card payments.

Owner/Assignor(s) Name

⠀

Signature

Services

Services

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Repair Authorization

Authorization to Repair

Rental Car Notice

One Time Endorsement and Refund Notice

Assignment of Rights and Direction to Pay Motor Vehicle Claim

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