Authorization to Repair, Direction of Pay, Explanation of Payment and Non-responsibility Waiver for City Collision

I hereby authorize City Collision to repair my vehicle as per the estimate. I understand that payment in full will be due upon the release of my vehicle, including any additional supplemental damage charges or insurance deductibles. I also understand that acceptable forms of payment include cash, money orders, cashier's checks, VISA and MasterCard (3.5% processing fee will be added) and that personal checks WILL NOT be an acceptable form of payment. I also grant City Collision and its employees permission to operate my vehicle (herein described on streets, highways, or elsewhere for the purpose of testing and inspection). An expressed mechanic's lien is hereby acknowledged on below vehicle to secure the amount of repairs thereto. I will not hold you responsible for loss or damage to the vehicle or articles left in vehicle in case of fire, theft, accident or any other cause beyond my/your control. Old parts removed from my vehicle will be junked unless otherwise noted. If insurance does not cover the loss and the vehicle is not repaired here, a $60 per day storage rate is applied from the day the vehicle arrived.

I authorize the insurance company to make Supplemental payments, on my behalf, directly to:
City Collision Inc
3015 Liberty Avenue, Pittsburgh PA 15201, Tax ID 251669169

*Vehicle:

*Customer Name:

*Address:

*Email:

*Phone (where you can be reached between 8a-5p):

CHOOSE YOUR SERVICE *REQUIRED

FULL SUSPENSION ALIGNMENT ($99.95): Utilizes our state of the art alignment machine to ensure your suspension is within factory specifications, which ensures optimum stability and eliminate premature treadwear.DELUXE CAR TREATMENT ($75): This service includes a thorough cleaning inside and out of your vehicle, ranging from vacuuming the interior, cleaning all windows, shining the tires, cleaning the wheels and a full vehicle hand wax. (Larger vehicles will be $100: E.g. Vans, SUV's, etc ... )PREMIUM CAR TREATMENT ($40): This begins a basic car wash, but also includes a thorough vacuuming and wiping of internal surfaces of the vehicle, cleaning of each of the windows, tire cleaning and wheel shine. (Larger vehicles will be $60: E.g. Vans, SUV's, etc ... )STANDARD CAR TREATMENT (Included): This is a basic car wash included as a courtesy of the shop.

Pre and Post-Repair Diagnostic Scan Authorization Form

This diagnostic work authorization form grants City Collision Inc. permission to perform a pre and post-repair diagnostic scan on your vehicle as part of the repair process. By accepting this procedure, you acknowledge the terms and conditions listed below. If you choose to decline this procedure, you acknowledge the repair shop will not be held liable for problems with the vehicle that cannot be detected without proper diagnostic scans. Data privacy – In the process of performing a diagnostic scan, City Collision Inc. will collect important historical vehicle data, including in some cases, the date, time and mileage of when a DTC was created. This information is
helpful in understanding if a problem is accident related or pre-existing. It is possible this information will be shared with your insurance company. Your acceptance of this procedure grants City Collision Inc. permission to share this information with others, including your insurance company. No personally identifiable information is collected during the pre or post-repair scan.

Disclaimers:

• Diagnosing vehicles has limitations. In some cases, modified vehicles may give false DTC’s. City Collision Inc. and
  its employees cannot be responsible for omission or errors caused by the information provided, or not provided,
  by the customer.
• All work performed by City Collision Inc. will be in accordance with Original Equipment Manufacturer (OEM)
  specifications and defaults. This includes, but is not limited to, any repairs, calibrations, integrations,
  programming and set points as indicated by the OEM by way of their designated sources of such information.
  City Collision Inc. is not responsible for any damage that results from, or to, aftermarket parts, or modifications
  from OEM factory specifications.
• Variations between vehicles, according to the make model and trim level, may limit the information captured
  during a pre or post-repair diagnostic scan.
• Depending on the condition of the vehicle, and the extent of the damage, and other factors outside the control
  of City Collision Inc. a factory scan tool may not see every system on the vehicle being scanned.
• City Collision Inc. is not responsible for any changes made to the vehicle after the vehicle leaves the shop.

While City Collision Inc. recommends a pre and post-repair scan on every vehicle, it is especially important to perform
these functions on newer, highly optioned, heavily damaged vehicles. Failure to do so significantly increases the risk
to the vehicle owner and occupants.

PLEASE INITIAL AND SIGN VEHICLE SCAN AUTHORIZATION FORM BELOW

I accept having a pre and post-repair diagnostic scan performed on my vehicle, even if my insurance
coverage does not pay for these procedures. In some instances, insurance coverage may not be determined until
after the diagnostic scans are performed.

Initials

Signature:

Note: Entering your name above is considered your signature

Date: