Full Name *

Email *

Phone *

Address *

City/State/Zip *

Drivers License # *

Legal Owner (Bank or Credit Union name)

Year / Make / Model / Color *

Vehicle License Plate

Vehicle Vin # *

Mileage

Insurance Company *

Claim # *

Adjusters Name

Adjusters Phone Number

Adjusters Email

Deductible Amount *

Date of Loss *

Consent *

I hereby authorize repair of the above vehicle. I agree that Michaels Collision Center is not responsible for loss of articles left in vehicle caused by fire, theft, or any other cause beyond our control or for delays caused by the unavailability of parts or shipping delays. I also grant permission to Michaels Collision Center’s employees to operate the above stated vehicle for the purpose of testing and or inspection. I understand and agree that to secure payment for the repairs thereto, an expressed mechanic’s lien on the above vehicle is acknowledged and further agree to pay reasonable attorney’s fees and court costs in the event that legal action becomes necessary to enforce this contract. I hereby authorize direct single party payment to be made to Michaels Collision Center for any repairs made to my vehicle.

Signature *

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