Authorization Form - Alpine Collisions

- Authorization Form
  Alpine Collision
- Registered Owner:
  First Name Last Name
- Owner email:
- Full Address:
  AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry
- Date of loss:
- Phone #
- Year / Make / Model
- Vehicle Lic. Plate/State#
- Vehicle Vin#
- Insurance Co.
- Claim No.
- Deductible Amount:
  I hereby authorize repair of the above vehicle. I agree that Alpine Auto 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 Alpine Auto 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 Alpine Auto Center for any repairs made to my vehicle.
- Consent*
  I authorize direct single party payment to be made To Alpine Collisions for any repairs made to my vehicle.
- Name*
  First Name Last Name Date
Do not fill this field.