MOTOR VEHICLE REPAIR AUTHORIZATION

Connecticut Public Act # 80-425 requires that we obtain written authorization before starting repairs on your vehicle.

WAIVER OF ADVANCE ESTIMATE

I request that repairs be performed on my vehicle without an advance estimate of their cost. By signing this form I authorize the reasonable and necessary costs to remedy the problems complained of up to a maximum of $ - Make a Selection - 100 200 300 400 500 600 700 800 900 1000 1250 1500 1750 2000 2250 2500 2750 3000 3250 3500 3750 4000 4250 4500 4750 5000 5250 5500 5750 6000 6250 6500 6750 7000 7250 7500 7750 8000 8250 8500 8750 9000 9250 9500 9750 10000 .00 US DOLLARS.  The repair shop my not exceed this amount without my written or oral consent.

Name            *

Date                 *

Make                   *

Model            *

Vehicle Year       *

 By making my choice below,

I agree

I do not agree

to the above statement and consider this my binding signature.

AUTHORIZATION OF ADDITIONAL REPAIRS

ASSIGNMENT OF PROCEEDS AND DIRECTION TO PAY

If additional repairs beyond the waiver estimate are discovered and related to the problems complained of, I request Barcello’s Auto Body to negotiate with      * insurance company in my behalf for any additional monies due.  I also authorize and direct the insurance company to pay directly to Barcello’s Auto Body all payments and supplements due on the above claim. (PROPERTY DAMAGE ONLY)  It is understood that if these payments are still sent to me I will forward it to Barcello’s Auto Body as they are received.  I also insist that Barcello’s Auto Body use only original equipment parts in the repair of my automobile.

 By making my choice below,

 I also agree   

I do not agree

to the above statement and consider this my binding signature.

*required entry