Name
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Address
Vehicle Year/Make/Model
Date of Loss
Insurance Carrier
Please Indicate Which Applies to You
Email
Phone
Authorization to Repair
Rental Car Notice
Please select one of the below required fields.
One Time Endorsement and Refund Notice
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
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Authorise