Repair Contract

Repair Contract
Customer's Full Name*

First NameLast Name
Date of drop-off*

MonthDayYear
Date
Time of drop-off*

Hour Minutes

AM/PM Option
Address*
Customer's Phone Number*
Please enter a valid phone number.
Customer's Email*
example@example.com
Vehicle Information:
Year
Make
Model
Vin Number
Mileage
License Plate Number
REPAIRS REQUESTED / NATURE OF PROBLEM:
MOTOR VEHICLE REPAIR AUTHORIZATION

Connecticut law requires that we obtain written authorization before starting repairs on your vehicle. By signing this Repair
Contract, you are authorizing the above repair facility to perform repairs on your vehicle and expressly authorizing it and its
employees to operate the above-listed vehicle on the streets, highways, or elsewhere for the purpose of testing and/or
inspection. Pursuant to Connecticut law, please initial where provided acknowledging the following:
I am aware of my right to choose the licensed repair shop where the damage to the motor vehicle will be repaired:*
Please Initial
CUSTOMERS WAIVER OF ADVANCE ESTIMATE

I voluntarily request that repairs be performed on my vehicle without an advance estimate of their cost. By signing this form, I authorize the
reasonable and necessary' costs to remedy the problems complained of up to a maximum of $ (cost)* The repair facility may not
exceed this amount without my written or oral consent.
Customer's Signature*

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AUTHORIZATION OF ADDITIONAL REPAIRS

If additional repairs beyond the waiver estimate above are discovered, I request the repair facility to make repairs as necessary
after obtaining my consent. The customer contacted the repair facility via telephone or email and authorized additional repairs on:
Date*

MonthDayYear
Date
Time*

Hour Minutes

AM/PM Option
Amount
New Cost
Employee Recieving Information*
Please ask the front desk
COMPLETION OF REPAIRS/ RETENTION OF PARTS

Repairs to your vehicle will not be completed on the same business day the vehicle is brought in. By signing below, you consent
to a later date of completion. If you wish to keep replaced parts, components, or equipment, you must initial here:
Initials*
LABOR CHARGES IN THE EVENT OF A TOTAL LOSS

In the event the above vehicle is not repaired by this repair facility, or is deemed a total loss, labor charges will be assessed for
services rendered.

CONSENT TO CHARGE STORAGE

By signing below you acknowledge that your vehicle was brought to this facility consensually (by your own choice); and that you
knowingly and voluntarily agree to pay storage for each day that your vehicle is kept on the repair facility premises, regardless of
whether your vehicle is repaired or declared a total loss. This repair facility has a posted storage rate of $150.00 per day.

PAYMENT

The above vehicle is being repaired for you — our customer. You are responsible for payment, including remittal of all insurance
checks and your deductible, if applicable. We may not be able to release your vehicle if we have not received full payment. By
signing this Repair Contract, you acknowledge and agree that if you, your insurer, or a third party insurer, fail to pay for services
rendered, interest will be added to the unpaid balance at a rate of 1.5% per month (18% per annum) and you will be responsible
for all reasonable attorney fees and court costs incurred by the repair shop to collect payment.

POSSESSION AND REPLEVIN

You agree that this repair facility shall have a lien against the vehicle for all unpaid services and shall have the right to retain the
vehicle until the repair facility is paid in full, as permitted by law. You agree to pay any and all costs and expenses, including reasonable attorneys fees, repair facility fees relating to any action in replevin.

CUSTOMER COPY

As the customer, you are entitled to a copy of this Repair Contract. By signing below, you acknowledge receipt of the same.
Customer Signature*

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Date*

MonthDayYear
Date
Time*

Hour Minutes

AM/PM Option
Witness Signature*

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Should be Empty: