Repair Authorization Form

Your Contact Information

Full Name:

Address:

City:

State:

Zipcode:

Home Phone Number:

Work Phone Number:

Cell Phone Number:

E-Mail Address:

Vehicle Information

Year:

Make:

Model:

Vin:

Mileage:

License Plate Number:

Insurance Information

Insurance Company:

Phone Number:

Claim or Policy #:

Authorization Form Disclaimer

I hereby authorize Francesco Auto Body, Inc. to provide an estimate of the repairs necessary to repair my vehicle. I acknowledge and agree that the above named repair facility shall contact me upon completion of the estimate and shall perform the repairs set forth on such estimate upon my verbal authorization.

I acknowledge and agree that my insurance carrier, , will pay the above named repair facility directly for repairs performed on my behalf as authorized by my signature below. I further acknowledge and agree that any deductible and depreciation that may apply under the terms of my insurance policy are my responsibility.

Vehicle Owner"s Signature: ( Type Your Full Name )

Validation Code:

Repair Authorization Form

Your Contact Information

Vehicle Information

Insurance Information

Authorization Form Disclaimer

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