Glass & Auto Service

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Car Make

Car Model

Is this an insurance claim?*

YesNo

Provide any pictures of damage

Requested Time*

I declare that I have full and legally binding authority to provide consent for the repair of my vehicle on my premises.

I hereby authorize Visionary Glass & Auto to perform all necessary and authorized repairs to my vehicle. In this regard, I understand that they may bring heavy equipment for the purpose of the repairs.

I hereby express my permission for Visionary Glass & Auto to use my premises to park their vehicle and equipment and assume the potential risks and liabilities associated with such activity on my premises.

I hereby defend, indemnify, release, discharge, and hold harmless, Visionary Glass & Auto its owners, affiliates, employees, agents, and representatives from any liability, injury, loss, damages whether personal or real, expenses, whether tangible or intangible, litigation costs by which they may incur in relation to the repair of my vehicle on my premises. It is my responsibility for keeping away children, pets, relatives and guests away from the work area during the repair in order to avoid or mitigate the risk of personal injury. I hereby declare that I am at least Eighteen (18) years of age and the legal and registered owner of the Premises or have the full authority to sign this agreement'*

I understand and agree

Signature*

Comments