First/Last Name:

Phone Number:

Email:

Vehicle Year, Make, Model, Color:

Insurance Company:

Claim Number:

I hereby authorize SBC Auto Collision to perform the necessary repairs to my vehicle, including any required parts, labor, and diagnostic work. I understand that any repair estimate is based on preliminary finding and does not cover additional parts, sublets or labor that might be required to complete the repair(s). If parts need to be returned due to cancellation of repairs, I will be responsible for any restocking fees, disassembly charges, and administrative fees, if applicable. SBC Auto Collision will dispose of old parts removed from the vehicle unless otherwise instructed. I also grant SBC Auto Collision employees permission to operate my vehicle on streets, highways, or elsewhere for the purpose of testing and/or inspection. Liability Disclaimer SBC Auto Collision will NOT be responsible for any loss or damage to the vehicle or articles left in the vehicle due to fire, theft, accident, or any cause beyond the control of the company. Customers are advised to remove personal belongings. SBC Auto Collision in no event shall be liable for special, consequential or indirect damages of any nature, and SBC Auto Collision’s maximum liability shall be no greater than the amount actually paid to, and received by, SBC Auto Collision for the services performed on the vehicle. Release of Liability, I hereby release and discharge SBC Auto Collision, its officers, employees, and agents from any and all liability, claims, damages, or losses arising out of or related to the repair of my vehicle, including any damage to my vehicle that occurs while it is in the possession of SBC, except for damage caused by SBC's gross negligence or willful misconduct. I acknowledge and agree that SBC is not responsible for any pre-existing conditions or damages that were not disclosed to SBC prior to repairs or damages that may occur after the vehicle has been returned to me. Vehicle Data Privacy During the repair process, SBC Auto Collision may perform a diagnostic scan, which could collect historical vehicle data, including but not limited to the date, time, and mileage at which diagnostic trouble codes (DTCs) were created. This information helps determine whether an issue is accident-related or pre existing. By authorizing repairs, you acknowledge that this information may be shared with your insurance company or other relevant third parties. SBC Auto Collision does not collect or store personally identifiable information during any scanning activity. Power of Attorney I hereby appoint SBC Auto Collision as my Power of Attorney to accept and endorse checks, drafts, or bills of exchange on my behalf for deposit into SBC Auto Collision’s account as payment for the repair of my vehicle. SBC Auto Collision is NOT responsible for rental vehicle charges (including insurance costs) incurred during the repair process. ● Estimated completion dates are not guaranteed and are subject to change based on parts’ availability and repair conditions. TYPE YOUR NAME BELOW TO SIGN (Registered Owner)

Deductible Amount: (If you have no deductible, type zero)

This deductible is due upon completion of the repair work and at the time of pick-up. Payment can be made via CASH (Exact Change), Debit/Credit Card (Visa, Mastercard, Discover, American Express). A 3.5% processing fee applies to all debit and credit card transactions. WE DO NOT ACCEPT PERSONAL OR THIRD-PARTY CHECKS Insurance checks must be endorsed and received prior to vehicle release. All repairs must be paid in full PRIOR to vehicle release SIGN BELOW for Deductible Amount (Acknowledging Deductible Amount):

Registered Owner

Date:

Time: