Vehicle Service Authorization

First Name

Last Name

Email

Phone

Payment Payment Insurance Company Self Pay

Year

Make

Model

Please check each box to authorize service Please check each box to authorize service I hereby authorize Hennessy Collision to DISSASSEMBLE AND COMPLETE the necessary repairs to my vehicle. A service advisor will provide me an oral/written evaluation of the damage. I authorize Hennessy Collision to Operate my vehicle for the purpose of testing inspecting or sublet repairs, pickup or delivery. I authorize Hennessy Collision to negotiate with insurance companies on my behalf DIRECTION TO PAY: I authorize all insurance payments be made to Hennessy Collision. I understand that I am responsible for all deductible payments and any pre-issued payments authorize all supplement amounts be paid to Hennessy Collision. An express mechanics lien is hereby acknowledged on the above vehicle to secure the amount of the repairs. I will not hold Hennessy Collision liablefor loss or damage to the vehicle in case of fire, theft or accident. HENNESSY COLLISION IS NOT RESPONSIBLE FOR ANY PERSONAL ARTICLES LEFT IN THE VEHICLE. I ACKNOWLEDGE I HAVE REMOVED OR WILL REMOVE ALL PERSONAL ARTICLES FROM MY VEHICLE. In order to diagnose necessary repairs, I authorize Hennessy Collision to access the vehicle's electronics data. Due to current issues with parts availability, materials, and labor shortages HENNESSY COLLISION WILL NOT BE RESPONSIBLE FOR RENTAL CHARGES BEYOND INSURANCE COMPANY APPROVED PERIOD OR POLICY LIMITS. This authorization is subject to your consent to electronic transactions an disclosures. You agree that your electronic authoirzation has the same force and effect and is the legal equivalent of your manual authorization signature. Checking this box, and the above boxes, indicates that YOU HAVE READ, UNDERSTAND AND AGREE to the above terms.