Work Authorization Form Customer information Name (required) Email (required) Driver's Licence (required) Driver's Licence Photo Contact InformationYour State AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyomingDistrict of Columbia City (required) Zip (required) Address (required) Phone Number (required) Home Number Vehicle Information Vehicle Make (required) Vehicle Model (required) Vehicle Year (required) Licence Plate (required) Insurance Company (required) Claim Number For Rental Vehicle (Optional) Additional vehicle operator: Additional Vehicle Operator's DL: Additional vehicle operator-2: Additional Vehicle Operator's DL-2: I hereby authorize the repair work to be done along with the necessary material, and hereby grant you/your employees permission to operate the vehicle herein described on streets, highways, or elsewhere for the purpose of testing/inspecting. An express mechanics lien is hereby acknowledged on the above vehicle to secure the amount of repairs thereto. Excel AutoBody Shop is not responsible for the availability of parts, or delays in part shipments beyond their control, nor for the loss, or damage to the vehicle, or articles left in the vehicle in case of fire, theft, or any cause beyond our control. I do hereby appoint the aforementioned business to accept on my behalf any, and all checks, drafts, or bills of exchange, and endorse all such checks, drafts, or bills of exchange for deposit to the aforementioned business account for credit on my account for repairs on my vehicle which has been released, and accepted. Direction To Pay In the event the insurance, or the adjustment company inadvertently mails the settlement/supplement check to me in error, I hereby agree to notify the said shop immediately, and I agree to deliver such check to the repair facility within 24 hours of my receipt of such check.The valid and collectible liability insurance and personal injury protection insurance of any authorized rental or leasing driver is primary for the limits of liability and personal iniury protection coverage required by ss. 324.021(7) and 627.736, Florida StatutesYou as a customer are responsible of any applicable deductible and any additional out of pocket expenses not cover by the Insurance Company Signature
