REPAIR AUTHORIZATION & DIRECTION TO PAY

REPAIR AUTHORIZATION & DIRECTION TO PAY
Vehicle Owner's Name
Vehicle Year, Make, Model
Insurance Co & Claim #
Deductible Amount $
Initials
Johnson Auto Body has my permission to order parts and repair my vehicle unless it is deemed an economic total loss. I acknowledge that I am responsible for payment of my deductible, if applicable.
Signature
Date

MonthDayYear
Date
I authorize * Insurance to pay Johnson Auto Body on my behalf.
Vehicle Owner Signature
Date

MonthDayYear
Date
I acknowledge that if my vehicle is deemed an economic total loss after disassembly, Johnson Auto Body

is not responsible for the reassembly of my vehicle.
Vehicle Owner Signature
Date

MonthDayYear
Date
I acknowledge Johnson Auto Body is not responsible for any loss or damage to my vehicle in case of fire, theft, or any causes beyond their control.
Vehicle Owner Signature
Date

MonthDayYear
Date
FORM MUST BE RETAINED IN CUSTOMER'S FILE
Should be Empty: