Work Authorization

Click here to download our work authorization form, or fill out and submit the online form below.

Owner/Agent Name (required):

Referred By (required):

Address(required):

City (required):

State (required):         
    

Zip (required):

Location (required)

Contact Information


Day Phone (###-###-####) (required):

Evening Phone (###-###-####) (required):

Cell (###-###-####) :

Email(1)(required):

Email(2):

Preferred Method of Contact (check all that apply) (required):
 Text Email Call Back

Vehicle Make (required):

Model (required):

Year(required)::

Color(required):

Vehicle Information


Insurance Company (required):

Referring Agent (required):

Claim Number:

I warrant and represent that I am the owner of the above described vehicle (hereinafter "the vehicle") or an authorized agent of the owner and that First Choice Collision llc. is authorized to repair the vehicle and provide the necessary services, part, and materials needed for the repair. I further authorize First Choice Collision llc. employees to operate the vehicle on streets and elsewhere for the purpose of testing and/or inspection. I acknowledge and understand that First Choice Collision llc. will have an express mechanics lien on and a security interest in the vehicle until such time as all indebtedness is paid in full. I further agree that First Choice Collision llc. shall not be responsible for loss or damage to articles left in the vehicle in case of fire, theft or any other cause. I further authorize First Choice Collision llc. to be my representative to negotiate with any insurance company/representative regarding the restoration of the vehicle to pre-accident condition and value. First Choice Collision llc. is authorized to endorse drafts from insurance company securing payment.


(required)
 Owner/Agent acknowledges payment in the form of Cash, Cashier's Check, Debt, Visa, Master Card, or Discover. No other forms of payment will be accepted. Owner/Agent warrants and represents that First Choice Collision llc. is not responsible for window tint or glass breakage or damage due to removal or work being performed on the vehicle. Owner/Agent acknowledges and understands that payment of insurance deductable is due at First Choice Collision llc. prior to release of the vehicle. Owner/Agent acknowledges and understands that all vehicles left over ten (10) days after scheduled pick-up date will incur a $10.00 per day storage fee. All work left over thirty (30) days will be subject to foreclosure of First Choice Collision llc. Mechanics Lien.

Signature (required):

Date (M/D/YY) (required):


Notice Pursuant to Texas Property Code 70.001


I warrant and represent that I am the owner of the above described vehicle or an authorized agent of the owner. I acknowledge and understand that First Choice Collision llc. will have an express mechanics lien on and a security interest in the vehicle until such time as all indebtedness is paid in full. I further acknowledge and understand that:

  • (1) If the vehicle is released by First Choice Collision llc., the vehicle remains subject to First
    Choice Collision llc. Mechanics Lien and or security interest until such time as all indebtedness is paid in full;
    and
  • (2) First Choice Collision llc. has the right to repossess and sell the vehicle in satisfaction of its lien
    or security interest if;

    • (a) The indebtedness remains unpaid for 30 or more days; or
    • (b) Any check, draft or negotiable instrument is dishonored for any reason; or
    • (c) The drawer or maker of the order has no account or the account on which it is drawn has been closed.

Signature (required):

Date (M/D/YY) (required):