Authorization To Repair / Direction To Pay

The following form is a legal agreement that 1) authorizes us to repair your car and 2) provides direction to pay. If you have any questions or would prefer a printed version, please contact us.

Section 1

I understand that the estimate I have received is based on the visual inspection made, and that after work has started more damage may be found. Any additional parts and labor will be charged where necessary, and will be charged at the invoices price either more or less. I understand that all part prices are subject to the invoices and delays may be incurred due to this fact. I understand that if there are rock chips or cracks in my windshield, they may spread due to high temperatures in the bake mode of the painting process. Also, windshields may crack or spread while pulling to repair body structure.

Section 2

I understand that Alpine Collision Inc. requires payment in full upon release of the vehicle. This means I will pay any insurance deductible directly to them by that time. I also understand that I may be required to pay Alpine Collision Inc. the entire remaining bill if the insurance company has not yet forwarded payment by the time of completion. Alpine Collision Inc. will submit supplemental billings to the insurance company on my behalf, but I accept responsibility for all outstanding charges. Any payments made by the insurance company after the vehicle is released and full payment is made, will belong to me, the customer. An express mechanic's lien is hereby acknowledged on the vehicle to be repaired to secure the amount of repairs there to, and I further agree to pay reasonable attorneys and court cost in the event legal action is necessary to enforce this contract.

Section 3

Alpine Collision Inc. is not responsible for loss or damage to articles left in the vehicle in case of fire, theft, and/or any other cause beyond our control, in addition to delays of parts in shipments of the supplier or transporter.

Section 4

The undersigned does hereby constitute and appoint Bruno Edelmann my (or our) true and lawful attorney to sign name, place and stead of the undersigned on any insurance checks, charge release forms or drafts issued by the insurance company covering any repairs to my vehicle. I authorized by myself (or ourselves) in whatever manner necessary to place checks or drafts in a cashable position.

Section 5

I have read and understand the estimate that I have been given, and the terms stated at and authorized services to be performed, and to test drive as necessary.

Section 6

I understand that as the insured (claimant exempt), if my insurance company does not pay the current labor rates of Alpine Collision, I will be responsible for paying the difference in full.

My insurance company

List your insurance company here or state N/A

Re Claim #

List your insurance claim number or state N/A

I am the

Insured

Claimant

I hereby authorize you to pay the following to Alpine Collision Inc.

Please list the amount in U.S. Dollars

Authorized signature

Typing your name below acts as an electronic signature. If you prefer or require a printed version with a non-electronic signature, please contact us so that we can discuss options.

First Name

Last Name

Providing your email address helps with tying this document to you, allows us to contact you if something on the form is amiss, and allows us to send you a copy of this form.

Phone

Providing your phone helps with tying this document to you and allows us to contact you if something on the form is amiss.

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Date

Please confirm today's date

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C/O Alpine Collision Inc.
256 Marmot Lane, PO Box 4150, Eagle, CO 81631
Phone: (970) 328-AUTO (2886)
Fax: (970) 328-1086
Tax ID# 84-1576203