VEHICLE DESCRIPTION

INSURANCE COVERAGE

AGREEMENT

Upon receipt of $250 deposit, we will schedule your vehicle for repair and coordinate with your insurance for the rest of the repair process. This deposit serves to secure your appointment, copy of estimate and partially cover the estimated cost of repairs and/or deductible. Please note that the final cost may vary depending on unforeseen circumstances or additional requested services. Any remaining balance will be due upon completion of the repairs. By providing this deposit, you acknowledge and agree to the terms and conditions outlined in this liability form.

AUTHORIZATION TO REPAIR / DIRECTIONS TO PAY

I hereby authorize Patriot Dent Repair to repair my vehicle along with any other necessary functions to restore my vehicle to pre-hail damaged condition. I also authorize employees or representatives of Patriot Dent Repair to operate the above vehicle for testing, inspection, and delivery at my own risk. I also understand that Patriot Dent Repair is not responsible in any way for items or articles left in my vehicle upon drop off.

If for any reason I receive a check from the insurance company made payable to me, I agree to pay Patriot PDR immediately upon receipt of payment. In order to expedite payment, I authorize Patriot PDR to endorse my name on insurance checks or drafts, and to deposit insurance checks or drafts for services rendered.