Authorization to Repair
Northside Collision Centers

CICERO Route 11 (P) 315-699-3148 (F) 315-699-9627 DMV REGISTRATION #4340652

DEWITT Manlius Center Rd. (P) 315-437-1111 (F) 315-437-1116 DMV REGISTRATION #7078661

BALDWINSVILLE E. Genesee Street (P) 315-638-4444 (F) 315-638-4441 DMV REGISTRATION #7092989

NAME _____________________________________________ Date _____________________

Address ______________________________________________________________________

Home Phone _________________________ Work Phone _________________________

YEAR __________ MAKE _________________ MODEL _____________________________

SOURCE ________________ 2/4 DOOR | WAGON | VAN ___________ LEASED / OWNED

INSURANCE CO. ____________________AGENT ________________________________

ADJUSTER _________________________________ PHONE/EXT ______________________

CLAIM# _____________________________________________________________________
I hereby authorize repair of the above vehicle. I agree that Northside Collision is not responsible for loss or damage to this vehicle and or loss of articles left in vehicle caused by fire, theft, or any other cause beyond our control or for delays caused by the unavailability of parts or shipping delays. I also grant permission to Northside Collision's employees to operate the above stated vehicle for the purpose of testing and or inspection. I understand and agree that to secure payment for the repairs thereto, an expressed mechanic's lien on the above vehicle is acknowledged and I further agree to pay reasonable attorney's fees and court costs in the event that legal action becomes necessary to enforce this contract. If new parts are not available, I understand and agree that Northside Collision reserves the right to repair such damaged parts, or if in Northside Collision's opinion, repair of parts rather than replacement is feasible Northside Collision reserves the right to do so, the charge for which will be adjusted accordingly between the part price and the labor required. If the responsible insurance company estimates the repair using aftermarket or used parts, Northside Collision will install those parts, but will not guarantee them. I understand it is the insurance company's responsibility to guarantee any aftermarket or used parts and agree to hold Northside Collision harmless. I understand and agree that whenever a windshield or back glass are removed there is a chance of breakage. I understand that Northside Collision is not responsible for the cost of replacement and that I must submit a glass claim to my insurance company for payment of replacement glass. I agree to hold harmless Northside Collision for any diminished value to the above listed vehicle due to the accident or repairs.

If supplemental damages, related to this claim are found after commencement of repairs, I authorize Northside Collision to do those repairs with the understanding that the responsible insurance company will bear the cost.

TERMS: The total amount of the repair charges must be paid before release of the above vehicle. If insurance coverage is to be applied against partial or total payment, I acknowledge that the insurance check/draft must be obtained by myself.

SIGNATURE __________________________________________ DATE__________________

REPAIR AMOUNT _____________________________________________________________

DIRECT PAY AUTHORIZATION
I hereby authorize payment to be made to Northside Collision for any repairs made to my vehicle.

VEHICLE OWNERS SIGNATURE ___________________________________ DATE ______________

TOTAL SUPPLEMENT ___________________________________________________ #007-5/00-1 M