Xoticar Automotive Repair Release Form

I hereby acknowledge that I understand the inherent risks and potential liabilities on having my vehicle's repair(s) undertaken. I likewise declare that I have full and legally binding authority to provide consent for the repair of my vehicle on my premises. I acknowledge the risk of any possible damage that may be incurred during the repair of my vehicle and by which I assume the liability and responsibility of such damage. I hereby authorize the Company XA to perform all necessary and authorized repairs to my vehicle. In this regard, I understand that they may bring heavy equipment for the purpose of the repairs as quoted and discussed with me. I hereby express my permission for the Company XA to use my premises to park their vehicle and heavy equipment and assume the potential risks and liabilities associated with such activity on my premises, including any damage to the property whether real or personal. The following has been explained to me and I acknowledge with full understanding:

There is a risk of spill of oil, grease, and/or other chemicals that may spill to my driveway, lawn, garage and/or any other personal property.

It is my responsibility for keeping away children, pets, relatives and guests away from the work area during the repair in order to avoid or mitigate the risk of personal injury.

I take responsibility for any damage to any property within the premises, whether real or personal, particularly including but not limited to, my driveway, landscaping, home, and/or personal injury, might occur.

The time spent in repairs through this method may take longer than usual. I accept and acknowledge any unforeseen delays or expenses which may accrue for not having the vehicle repaired on time.

During repair, there may be unforeseen damaged parts that the mechanic might not see and might get damaged. The mechanic shall inform me of these damaged parts and further assessment shall be made. This shall incur additional costs for repair on my part should I ask for it to be repaired as well.

I hereby waive my right to sue the Company for any and all damages, injuries, or death that I or my family might incur during and in connection with the repair of my vehicle. Further, I hereby defend, indemnify, release, discharge, and hold harmless, the Company, its owners, affiliates, employees, agents, and representatives from any liability, injury, loss, damages whether personal or real, expenses, whether tangible or intangible, litigation costs by which they may incur in relation to the repair of my vehicle in my premises. I hereby declare that I am at least Eighteen (18) years of age and the legal and registered owner of the Premises or have the full authority to sign this agreement.

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Vehicle Year

Vehicle Make

Vehicle Model

Vehicle Mileage

Vehicle Tag#

Signature

Date Signed

Date