Authorization & Release of Liability

Authorization & Release of Liability

For Digging Out Frozen/Stuck Loads with SECCRA Equipment
Company
Primary Contact*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Scope of Authorization*

Blanket Authorization: I authorize SECCRA to provide frozen/stuck load assistance for any and all vehicles, trucks, trailers, or equipment that are owned, leased, rented, operated, dispatched, or otherwise controlled by the customer named above, regardless of whether specific equipment is identified in this form.This authorization is valid for 12 months from the date of signature and expires automatically unless renewed.One Time Authorization: I am requesting authorization for today’s visit only. This authorization expires upon completion of service for this visit.

Acknowledgement of Risk
I understand that SECCRA may use heavy equipment to break apart, loosen, or remove frozen or compacted material and that this activity carries inherent risks, including but not limited to:
- Scratches, dents, tears, bent metal or damaged liners
- Damage to tailgates, hinges, tarps, hydraulics, electrical systems, or cargo
  Loss of material or spillage
- Delays or inability to unload
SECCRA does not guarantee successful unloading or avoidance of damage.
Fee Agreement
I acknowledge and agree that:
- A fee is charged each time this service is provided.
- The fee is the current rate posted on SECCRA.org at the time of service.
- Prices may change without notice; the posted rate always applies.
- SECCRA may require payment before service or charge to an account depending on customer status.
Release of Liability & Hold Harmless
By submitting this form, I:
- Request assistance from SECCRA
- Accept all associated risks
- Release, indemnify, and hold harmless SECCRA, its officers, employees, agents, and equipment operators from all claims, liability, or damages arising from or related to this service
- Understand this release applies to negligence but not to gross negligence or intentional misconduct
If Blanket Authorization is selected, I represent and warrant that I am authorized to legally bind the business entity named above.

Signature
By signing below, I confirm that I have read and understand this authorization and release, and I agree to all terms and conditions stated above.*

Clear
Name*

First NameLast Name
Title/Role*
Date

MonthDayYear
Date
Term in Days
Expiration Date
Should be Empty:

Acknowledgement of Risk