Repair Authorization & Direction to Pay

Fill out the form below to authorize repairs to your vehicle.

  • I Hereby Authorize The Estimated Repair Work To Be Done Along With The Necessary Material, And Hereby Grant You, And/Or Your Employees Permission To Operate The Vehicle Herein Described On Street, Highways, Or Elsewhere For the Purpose of Testing And/Or Inspection. An Express Mechanic’s Lien Is Hereby Acknowledged On Above Vehicle To Secure The Amount Of Repairs Thereto.

    NO CAR RELEASED Until Payment Is Made In Full. Deductible And Insurance Check Or Proof Of Loss Must Be Received Before Vehicle Will Be Released. Please Be Certain All Payees (Including All Lien Holders) Have Endorsed the Insurance Check Prior To Completion Of Repairs.

    MCCOLLUM INC. is Not Responsible For Loss Or Damage To Cars Or Articles Left In Cars In Case Of Fire, Theft, Or Any Other Cause Beyond Our Control.

    KNOW ALL MEN BY THESE PRESENTS that I (or we), the undersigned, do hereby constitute and appoint MCCOLLUM INC. as my (or our) true and lawful agent and attorney-in-fact to endorse in the name, place and stead of the undersigned and check of draft issued by your insurance company (listed above) to cover all or part of repairs to my (or our) automobile which are authorized by me (or us) in whatever manner is necessary to negotiate such a check or draft for the purpose of paying for such repairs. I (or we) hereby ratify and confirm whatever action said agent and attorney-in-fact may take in such regard by virtue hereof.

    Please type your name in the field below and indicate your agreement with the above.
  • MM slash DD slash YYYY
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