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
YesNo
YesNo
YesNo
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*

I AGREE
POWER OF ATTORNEY
I AGREE
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

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Should be Empty:

AUTHORIZATION FORM