Work Authorization Form

    AXELROD COLLISION REPAIR AUTHORIZATION FORM

    Supplemental Customer Acknowledgement Form

    ESTIMATE: UNDER OHIOLAW YOU HAVE THE RIGHT TO AN ESTIMATE IF THE EXPECTED COSTOF REPAIRS OR SERVICES WILL BE MORE THAN FIFTY DOLLARS, INITIAL YOUR CHOICE. YOUR B I L LWILL NOT BE HIGHER THAN THE ESTIMATE BYMORE THAN TEN PERCENT UNLESS YOU APPROVE A LARGER AMOUNT BEFORE REPAIRS ARE FINISHED.

    Please Select Your Choice:
    WrittenOralNo Estimate

    Replaced Parts: Replacement parts will be returned to you unless, subject to manufacturer's warranty, core charge or otherwise specified.

    Discard Parts:
    YesNo

    Use of Aftermarket, Reconditioned, orLKQ Parts: The Ohio Department of Insurance requires that when LKQ (Like Kindand Quality), aftermarketor reconditioned parts are used, the customer must be informed.' The preliminary estimate and/or estimate or record may have been prepared based upon the use of one or more aftermarket parts supplied by sources other than the manufacturer of your vehicle. If so, aftermarket, reconditioned, and LKQ parts are identified in the preliminary estimate and/or the estimate of record. Warranties applicable to these aftermarket parts are provided by the parts manufacturer or distributor, rather than by your own, motor vehicle manufacturer.

    I understand that a charge will be imposed for disassembly, reassembly or partially completed work and agree to pay the same. Such charges will be directly related to the actual amount of labor nd parts involved in the inspection, repair or service.

    Authorization of repairs: I hereby authorize Axelrod Collision Center, LLC to repair my vehicle as described on either the attached preliminary estimate or estimate ofrecord. I agree that employees of Axelrod Collision Center,LLC may operate my vehicle for the purpose of testing and delivery. I agree that Axelrod Collision Center, LLC is not responsible for damage, theft, fire, vandalism, and/or loss of items left in the vehicle due to reasons beyond normal control, nor for any delays caused by unavailability or delayed availability of parts or materials for any reason. An express mechanic's lien is hereby acknowledged on the above vehicle to secure the amount of repairs thereto. I authorize said repair facility to order and accept delivery of parts and/or services required to restore the vehicle to its pre-loss condition as described on the attached preliminary estimate and/or estimate of record. I agree to pay in cash upon completion of the repairs or by other means as approved by the repair facility.

    Repair facility hereby expressly disclaims al warranties, either express or implied, including any warranties of merchantability or fitness for a particular purpose, regarding any products or services provided, unless otherwise indicated on the repair order, and neither assumes nor authorizes any other person to assume for it any liability in connection with the sales of any parts or this repair. This disclaimer in no way affects the provisions ofany manufacturer or other supplier's warranty.

    This acknowledgement disclosure is supplemental to and incorporated herein by reference into the above-mentioned Customer's Preliminary Estimate, and/or Estimate of Record, and/or Repair Order.

    Power of Attorney: I DO HEREBY appoint Axelrod Collision Center,LLC as my attorney in fact, to accept on my behalf any and all checks, and to endorse all such checks for deposit to Axelrod Collision Center, LLC account for credit on my account for the repairs on my vehicle, which has been release and accepted.

    BY CLICKING SUBMIT I AM DIGITALLY SIGNING THIS FORM AND GIVING AUTHORIZATION AND POWER OF ATTORNEY TO AXELROD COLLISION AS STATED FORTH IN THIS DOCUMENT.