| E-mail Address: * | | | Date * |
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| Customer Name * |
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| Last 4 Digits of SSN * |
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| I underdstand that providing the last 4 digits of my SSN acts as a personal signature. * |
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| I hereby authorize Gulf Shores Collision Center, including its officers, agents and employees [hereafter referred to collectively as [Gulf Shores Collision], to estimate and repair my vehicle unless it is considered a total loss. I grant Gulf Shores Collision permission to operate my vehicle for the purposes of diagnosis, testing and inspection. An expressed mechanic`s lien is acknowledged for the amount of repairs in addition to releasing the business from liability for loss or damage to vehicle or articles left in vehicles in case of fire, theft, or other causes beyond the control of Gulf Shores Collision. I authorize my vehicle to be transported to any other location under the ownership of Fairhope Paint & Body Shop, Inc. to perform repairs authorized above, if necessary. * |
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| POWER OF ATTORNEY – GULF SHORES COLLISION CENTER, 3907 GULF SHORES PKWY, GULF SHORES, AL36542: I do hereby appoint the aforementioned business as my attorney, in fact, to accept, on my behalf, any and all checks or drafts and to endorse all such checks and drafts for deposit to the aforementioned business for credit on my account for repairs to my vehicle. * |
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| FINANCIAL POLICY STATEMENT: It is the policy of Gulf Shores Collision to collect all payments covering repair costs at the time of vehicle delivery. As the vehicle owner, you are responsible, in full, for the entire cost of your vehicle repair. Unless prior arrangements have been made between Gulf Shores Collision and the insurer paying your bill, you are responsible for all payments. All deductible payments and/or parts betterments are due by the vehicle owner, in full, at the time of delivery. Gulf Shores Collision does not `save` or `bury` deductibles. Approved methods of payment include: cash, cashier’s check, insurer`s draft, personal check $250.00 limit on personal checks, Visa, Master Card and Discover. If any payment is made directly to you for repairs performed by Gulf Shores Collision, you recognize an obligation to promptly remit same payment amount to Gulf Shores Collision. * |
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| CUSTOMER UPDATES: In effort to best serve you, our customer; it is the policy of Gulf Shores Collision to provide you with accurate and up-to-date information about the repair progress. Please choose the frequency and type of communication process you want us to utilize to contact you. * |
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| CONTACT METHOD * |
Home
Cell
Work
E-mail
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| Please provide the contact information chosen in the previous question. * |
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| * Required | |
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