Authorization FormFacebookThis field is for validation purposes and should be left unchanged.Name(Required) First Last Email(Required) Phone(Required)Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Claim Number(Required)(If paying out of pocket, please write “Cash Pay”.)How did you hear about us?—Family / FriendReferralInternet / Google SearchOtherAre you getting a rental from the insurance company? Yes NoHow often would you like to be kept informed? Every couple of days Once a week Just let me know when it’s doneDo you have a reservation number?Payment Responsibility Your Insurance Their Insurance OtherWas your car pushed? Did it spin out or hit any curbs as a result of the accident? Yes NoVehicle Make(Required)Vehicle Model(Required)Vehicle Year(Required)Wireless Provider(If you would like to receive text message updates, we need your cell phone provider.)Today's Date(Required) MM slash DD slash YYYY Signature(Required)Please enter the last four digits of your license to sign this form electronicallyDisclaimer(Required) I agree to the terms below.I, THE UNDERSIGNED, AGREE TO THE FOLLOWING CONTRACT: I authorize immediate commencement of work on the vehicle herein, including any hidden damage not apparent on original inspection. I appoint the shop as my agent to negotiate on my behalf and represent me to any and all parties, including insurance companies and their representatives so that a high standard of repairs can be met. Shop employees may drive said vehicle for repair work purposed I appoint Clean Fleet and its officers and employees as my authorized agents and representatives as defined in R. S. 10:3.403, and I authorize them in such capacity to endorse my signature on any insurance checks, drafts, or directions to pay issued for repairs on said vehicles and I relieve and release them from any liability in connection therewith. In the event new parts are not immediately available, used parts may be substituted or original parts repaired. All parts replaced are on an exchange basis. Payment is due upon completion of work, to be paid by insurance, cash, cashier’s check, or approved credit or debit card. Storage fee of $31.50 per day of outside storage or $38.00 per day inside storage will be charged, beginning 48 hours after work is completed and until said work is paid in full and the vehicle released to me. A 25% restocking fee will be charged for all preorder parts if repairs are not to be performed. In the event of default in payment, I agree to pay attorney’s fee, all cost, collection charges and interest at an annual rate of 18% on the unpaid balance and release and hold the shop harmless from all claims for theft and damages to vehicle and/or its contents. This shop may exercise lien rights according to the statues of the State of Louisiana. I agree to notify lien holder of shop’s rights here under and I authorize lien holder pursuant to R. S. 10:3 403 it endorse all or any insurance checks or drafts, as my agent for payment of repairs to this body shop at any time without further notice. I agree to pay prices as posted and explained here at this body shop. Parts and labor are subject to change without notice, I received a copy of this agreement upon signing. The undersigned further agrees that any claim asserted by the undersigned against this shop not covered by this shop’s garage keeper’s liability insurance coverage shall be submitted to the Better Business Bureau for arbitration which shall be legally binding on the shop and the undersigned. FOR ALL INSURANCE COMPANY CHECKS THAT INCLUDE LIENHOLDER AS PAYEE: I UNDERSTAND THAT THE WORK DONE BY CLEAN FLEET MUST BE INSPECTED BY MY LIEN HOLDER BEFORE THAT LIENHOLDER WILL ENDORSE THE INSURANCE COMPANY CHECK. I FURTHER UNDERSTAND THAT I AM RESPONSIBLE FOR HAVING MY INSURANCE COMPANY’S CHECK RECEIVED BY CLEAN FLEET NO LESS THAN TWO WORKING DAYS BEFORE MY VEHICLE IS DELIVERED TO ME.CAPTCHA
