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Check in sheet
Collision Repair
1
2
Driver Information
Name
(Required)
Date in
(Required)
MM slash DD slash YYYY
Desired Completion
Take your time
ASAP
Year
(Required)
Make
(Required)
Model
(Required)
Phone
(Required)
Permission to text
(Required)
Yes
No
Dash lights on
Driving problems
Unrelated damage
Additional work requested, with price
Customer pay
Yes
No
Insurance company
(Required)
Claim Number
(Required)
Detuctable ammount
(Required)
Will you be in a rental?
Yes
No
Rick's Auto Body Shop repairs vehicles per Indiana State Law as well as the manufacturer's recommended regulations and guidelines. Please be advised that some insurance policies do not adhere to these recommendations.
Consent
(Required)
I hereby authorize the repair work to be done along with the necessary material, and hereby grant you/your employees permission to operate the vehicle(s) herein described on streets, highways, or elsewhere for the purpose of testing/inspecting. Rick’s Auto Body Shop, Inc is not responsible for the availability of parts, or delays in part shipments beyond their control.
(Required)
Consent
(Required)
I do hereby appoint the aforementioned business to accept on my behalf any, and all, checks, drafts, or bills of exchange for deposit to the aforementioned business account for credit on my account for repairs on my vehicle which has been released and accepted.
(Required)
I authorize
Insurance Company to pay Rick’s Auto Body Shop Inc on claim
#
. In the event the insurance company or the adjustment company inadvertently mails the settlement/supplement check to me, or deposits it into my account in error, I hereby agree to notify said shop immediately and agree to deliver such check to the repair facility within 24 hours of my receipt of such check/payment. ***Additional work requested, with price, initialed by shop rep.
Customer Printed Name
(Required)
Customer Signature
(Required)
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Consent
(Required)
By checking this box, I agree to sign this form electronically.
(Required)
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Phone
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