Van Collision Center

First Name*

Last Name*

Middle Initial

Email*

Phone*

Cell Phone*

Mobile Carrier

Prefered Contact Method

Phone

Cell Phone

I agree to receive text messages from Van Collision Center. I understand that message and data rates may apply.

Address Information

Street

Apartment

City

State

Zip Code

Vehicle Information

Year

Make

Model

Referred By

Insurance Company

Deductable

Agents Name

Comments

Removal of Personal Items

Removal of Personal Items

I have removed all personal items from my vehicle, plus all un-mounted stereo equipment.

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Date

Power Of Attorney & Direction To Pay

POWER OF ATTORNEY & DIRECTION TO PAY

I do hereby appoint Van Chevrolet and its representatives as my attorney, in fact to accept on my behalf all checks and drafts for deposit to the aforementioned business account for credit to my account for the repairs on the above said vehicle. Accepted and Authorized for Repairs.

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Date

Authorization To Repair

AUTHORIZATION TO REPAIR

I hereby authorize the repair work to be performed along with the necessary material and agree that you are not responsible for loss or damage to the vehicle, articles in the vehicle, fire, theft, or any other cause that is not a direct result of your gross negligence or for delays caused by unavailable parts or delays in parts shipped by the supplier or transporter. I hereby grant you and/or your employees' permission to operate the vehicle herein described on streets or highways for inspection. An expressed mechanic's lien is hereby acknowledged on above vehicle to secure the amount of repairs thereto. Customer is aware of damage noted on diagram, and agrees that it occurred prior to acceptance by Van Chevrolet. 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 ten (10) days after the dealership has notified the Customer that the repairs are completed, the dealership may charge daily storage fees at rates that are ordinary and customary for the area, but not to exceed $100.00 per day.

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Date

Arbitration

ARBITRATION

Customer agrees that any controversy or claim by or between customer and Van Chevrolet (including any of its agents and representatives) of any kind or nature whatsoever shall be settle by arbitration in accordance with the rules of the American Arbitration Association or the National Arbitration Forum. There shall be no class action arbitration or relief. The arbitration award and/or order shall be final and binding on the parties to the arbitration. Confirmation of and entry to judgment on the award and/or decision rendered by the arbitrator may be entered in any court having proper jurisdiction. Unless the arbitrator determines that applicable law or the enforceability of this arbitration clause requires otherwise, each party shall bear its own costs and expenses (including attorney’s fees and expenses) in connection with any arbitration proceeding. Both customer and Van Chevrolet retain the right to exercise self-help remedies, filing or answering suit, or seeking or obtaining provisional remedies from a court. If any of this arbitration clause is deemed or found to be unenforceable for any reason the rest of the arbitration clause remains enforceable.

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Date

Repair Authorization Form

Address Information

Vehicle Information

Comments

Removal of Personal Items

Power Of Attorney & Direction To Pay

Authorization To Repair

Arbitration