Authorization Of Repair Form

We want to get you back in the drivers seat of your vehicle as soon as possible! To speed up the process and save you a trip to our location, we’ve created this Authorization Form for you to fill out and submit online. This form will give us authorization to proceed with repairs on your vehicle based on the estimates you have been provided. All fields are required, and you must read and agree to the terms and conditions.

Authorization Form

General Information
- Name*
- Email*
- Phone*
- Vehicle Year Make & Model*
- Vehicle License Plate Number*
- Insurance Claim Number
- Address*
  Street Address Address Line 2 City State ZIP Code
- Date*
  Month
  Day
  Year
Terms & Conditions
• By signing this form, I understand and agree to the following terms and authorize Roadrunner Collision Center, LLC to repair the above-mentioned vehicle. I hereby authorize the teardown of vehicle for estimate, all approved repair work by insurance company and/or vehicle owner, parts ordering, and materials as indicated on repair estimate. The estimate of repairs includes parts, labor, and diagnosis. We may find on further inspection, additional parts or repair needed which may adjust the final total. You or your insurance company may be contacted for additional monies to correct these additional repairs. We are not responsible for loss of damage to your vehicle from fire, theft, accident, or any other cause beyond our control. Our employees, at your risk, will make test drives up to highway speeds for diagnosis and final check. If vehicle is returned to customer before authorized repairs are performed, a diagnostic and Administration charge, including reassemble, any advanced charges will be made. An expressed mechanic’s lien is hereby acknowledged on the above vehicle to secure amount of repairs thereto. Customer agrees that he/she will be jointly and severally responsible and liable for payment of all charges for labor, parts, material, and accessories, sublet repairs to the vehicle, and any other charges incurred under this Agreement and payment in full shall be made prior to the release of the vehicle. If the vehicle is not picked up within five (5) days after Roadrunner Collision Center has notified the customer that the repairs are completed, Roadrunner Collision Center may charge daily storage fees at rates that are ordinary and customary for the area, but not to exceed $100.00 per day
- Agreement*
  - I have read and agree to the Terms and Conditions.
- Signature*
- Date*
  Month
  Day
  Year
Power of Attorney
• I do hereby appoint Roadrunner Collision Center, LLC as my representative in fact to accept on my behalf any and all checks, drafts, directions to pay or bills of exchange and to endorse all such checks, draft, directions to pay or bills of exchange for deposits to Roadrunner Collision Center, LLC account for credit on my account for repairs on the above said vehicle which has been Released, accepted, and authorized for repairs.
- Signature*
- Date*
  Month
  Day
  Year

Authorization Of Repair Form

Authorization Form

General Information

Terms & Conditions

Power of Attorney