Work Authorization Form Owner/agent - Westside Collision printable pdf download

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Work Authorization Form

Owner/Agent:_____________________________________________________________________

Address:__________________________________________________________________________

City:_________________________ State:_____________________ Zip:______________________

Day Phone:_________________ Evening Phone:_________________ Cell:____________________

E-Mail:____________________________________ Referred by:____________________________

Vehicle Make:____________ Year:_________ Model:__________ License Plate:_______________

Insurance Company:_____________________________ Agent:_____________________________

I warrant and represent that I am the owner of the above described vehicle (hereinafter “the vehicle”) or an authorized agent of the owner and that

Westside Collision Inc. is authorized to repair the vehicle and provide the necessary services, part, and materials needed for the repair. I further

authorize Westside Collision Inc. employees to operate the vehicle on streets and elsewhere for the purpose of testing and/or inspection. I

acknowledge and understand that Westside Collision Inc. will have an express mechanics lien on and a security interest in the vehicle until such time

as all indebtedness is paid in full. I further agree that Westside Collision Inc. shall not be responsible for loss or damage to articles left in the vehicle

in case of fire, theft or any other cause. I further authorize Westside Collision Inc. to be my representative to negotiate with any insurance

company/representative regarding the restoration of the vehicle to pre-accident condition and value. Westside Collision Inc. is authorized to endorse

drafts from insurance company securing payment.

Please initial below:

Owner/Agent acknowledges payment in the form of Cash, Cashier’s Check, Debit, Visa, Master Card, or

Discover. No other forms of payment will be accepted.

_____ Owner/Agent warrants and represents that

is not responsible for window tint or glass breakage or

Westside Collision Inc.

damage due to removal or work being performed on the vehicle.

_____ Owner/Agent acknowledges and understands that payment of insurance deductable is due to

prior to

Westside Collision Inc.

release of the vehicle.

_____ Owner/Agent acknowledges and understands that all vehicles left over ten (10) days after scheduled pick-up date will incur a

$10.00 per day storage fee. All work left over thirty (30) days will be subject to foreclosure of

Mechanics

Westside Collision Inc.

lien.

Signature:_________________________________________ Date:__________________________________________

Notice Pursuant to Texas Property Code 70.001

I warrant and represent that I am the owner of the above described vehicle or an authorized agent of the owner. I acknowledge and

understand that

will have an express mechanics lien on and a security interest in the vehicle until such time as

Westside Collision Inc.

all indebtedness is paid in full. I further acknowledge and understand that: (1) if the vehicle is released by

, the

Westside Collision Inc.

vehicle remains subject to

mechanics lien and/or security interest until such time as all indebtedness is paid in

Westside Collision Inc.

full; and (2)

has the right to repossess and sell the vehicle in satisfaction of its lien or security interest if; (a) the

Westside Collision Inc.

indebtedness remains unpaid for 30 or more days; or (b) any check, draft, or negotiable instrument is dishonored for any reason; or

Signature:_________________________________________ Date:__________________________________________

Work Authorization Form Owner/agent - Westside Collision

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