MSACC Authorization and Direction to Pay
Name
First Name
Last Name
Your Email
Your Telephone
Vehicle
VIN
You are hereby authorized to make the estimated repairs, including supplemental damage charges, and I hereby grant you and/or your employee's permission to operate the estimated vehicle on streets, highways, or elsewhere for the purpose of testing and/or inspection. An expressed mechanic's lien is hereby acknowledged on the estimated vehicle to secure the amount of repairs thereto. You will not be held responsible for loss or damage to the vehicle or articles left in the vehicle in case of fire, theft, accident, or any other cause beyond your control.I authorize any and all payments payable to Mike Smith's Automotive Collision Center. I authorize Mike Smith's Automotive and Collision Center to act as Power Of Attorney to sign all payments for the above described vehicle.
*
I Agree To The Above Terms & Conditions
Print Name:
Type your Name
Signature
Date
-
Month
-
Day
Year
Date
Preferred method of contact: Telephone or E-Mail
Cell Phone
Home Phone
Work Phone
Email
Name of Insurance Co. Responsible for damage
Insurance Telephone
Submit
Should be Empty: