Authorization Form Authorize body shop work Name(Required) First Last Phone(Required)Email(Required) Insurance CompanyVehicle Make and Model(Required)Year(Required)HAVE YOU RECEIVED any checks or had money directly deposited from an insurance company for this claim prior to bringing your car for repair? Yes No I don't know Consent(Required) I authorize Leroy's Body Shop.I hereby authorize LeRoy’s Body Shop to begin repairs and/or any teardown required by my insurance company on the above-described vehicle. This estimate of repair includes parts, labor and diagnosis. If, on further inspection, additional parts or repairs are needed I will be contacted. LeRoy’s Body Shop is not responsible for any loss or damage to my vehicle or its contents from fire, theft, accidents, or any cause beyond their control. All tests, including driving my vehicle, will be made by their employees or sublet vendors, at my risk. LIMITED POWER OF ATTORNEY I hereby appoint LeRoy’s Body Shop as my Attorney in Fact to accept on my behalf all checks, drafts or bills of exchange and to endorse all such checks, drafts or exchange for deposit to the aforementioned business account for credit on my account for repairs on my vehicle.FORMS OF PAYMENT.(Required) I have read and understand my payment options.Leroy's Body Shop accepts cash, check, debit or credit card. If you use a debit card, there is no processing fee. If you use a credit card, a 3% processing fee will be charged automatically. Signature(Required)Check the Consent box above and type your name as a signature of authorization.Date of Submission(Required) MM slash DD slash YYYY Today's date
