Authorization Form and POA

AUTHORIZATION FORM

PLEASE FILL THIS OUT AT YOUR EARLIEST CONVENIENCE
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

CityState / Province

Postal / Zip Code
Rental Vehicle?
Any Injuries?
Passengers?
Explanation of Accident?
Insurance Company: (fill in the blank)*

Claim #: (fill in the blank)*

Vehicle Year: (fill in the blank)*

Vehicle Make: (fill in the blank)*

Vehicle Model:(fill in the blank)*
AUTHORIZATION OF WORK
I hereby authorize the repair work herein set forth to be done with the necessary materials and agree that Network is not responsible for loss or damage to vehicle or articles left in the vehicle in cases of fire, theft and / or any cause beyond our control. I hereby grant Network and employees / sub contractors permission to operate the vehicle herein described on your property or elsewhere for the purpose of testing and/or inspection. An express mechanic's lein is hereby enforced if all required payments are not made to the facility upon completion of repairs
POWER OF ATTORNEY
Customer hereby grants NETWORK COLLISION and authorized employees the limited Power of Attorney to endorse on the customers behalf. All insurance company checks made payable to NETWORK COLLISION or to customer regarding described vehicle and claim. The limited Power of Attorney expires upon full payment of the vehicle
DIRECTION TO PAY

Please send al payments directly to Network Collision. Customers please do not cash the insurance checks. Any cashed checks will result in a 3% charge for Credit/Debit. No fee for cash/money order/cashier's checks.
Signature
Date

MonthDayYear
Date
Should be Empty:

AUTHORIZATION FORM

AUTHORIZATION OF WORK

POWER OF ATTORNEY

DIRECTION TO PAY