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AUTHORIZATION TO REPAIR

Policy Holder/Claimant*

Insurance Company*

Claim Number*


AUTHORIZED AND ACCEPTED: OCR is hereby authorized to make repairs as specified on my estimate. I understand that payment in full will be due upon release of the vehicle, including supplemental damage charges. I hereby grant OCR and its employees permission to operate the vehicle herein described on streets, highways or elsewhere for the purpose of testing and/or inspection. An express mechanic’s lien is hereby acknowledged on the above vehicle to secure the amount of repairs thereto. OCR will not be held responsible for loss or damage to the vehicle or articles left in the vehicle in case of fire, accident or any other case beyond OCR’s control. OLD PARTS ARE JUNKED UNLESS INSTRUCTED!

PLEASE UNDERSTAND THAT DUE TO MANY UNFORESEEN CIRCUMSTANCES IN THE REPAIRING OF VEHICLES, WE REGRET THAT WE CAN ONLY ESTIMATE NOT PROMISE A COMPLETION DATE AND TIME.

Authorized by:*

Date* mm/dd/yyyy:


I authorize any and all payments for repairs as specified on Repair Order # to be payable directly to OFFUTT COLLISION REPAIR on my behalf.

Authorized by:*

Date* mm/dd/yyyy:


I authorize OFFUTT COLLISION REPAIR to act as “Power of Attorney” to sign/endorse all payments made on my behalf for the above specified repair order.

Authorized by:*

Date* mm/dd/yyyy:


Please provide an email address and the best number for phone/text:

My Email address is:

The best phone number to reach me is:


THE DEDUCTIBLE WILL BE DUE AT THE TIME OF PICKUP.


10106 S 15th St
Bellevue, Nebraska 68123
(402) 291-5599

Hours Of Operation:
M-F 7:30am - 5:00pm

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