I, the “Customer” hereby authorize Burl’s Collision Center, Inc. (hereafter: Burl’s Collision Center), my chosen repairer, to perform the repair of the vehicle as noted above. I agree that I will assist Burl’s Collision Center in dealingdirectly with the insurance carrier and will send and submit all forms and documents reasonably necessary to facilitate the full payment of the claim. I understand that my repairer has no relationship with the insurance company and is under no financial, legal, moral, or ethical obligation to interact with the insurer directly, and that their doing so is merely as a courtesy to me as their valued customer.

I further understand as the customer, I am responsible for all costs associated with the repair of the vehicle and that all billings are to be paid, in full, prior to the release of the above noted vehicle.

I further understand that it is the insurer who has the contractual obligation and/or duty to restore the vehicle to its pre-accident condition and value. It is the repair facility’s responsibility to do those repairs for which they receive correct compensation and do so in a professional and workmanlike manner. If applicable, I understand that Burl’sCollision Center will use the “insurer’s provided estimate for informational purposes only” and that Burl’s Collision Center will prepare and provide the assessment of damages and estimate of repair costs and that such repairs will be performed and billed relative to same and such repairs performed and paid for will be backed by a “Limited Lifetime Warranty” provided by Burl’s Collision Center. Note that some restrictions may apply. Furthermore, I agree that I will fully and unconditionally hold harmless Burl’s Collision Center, its employees, directors, affiliates, owners, managers, and their heirs from all actions, legal and otherwise, known or unknown, and from all expenses, including reasonable attorney fees and costs incurred to defend such actions from any entity, insurance company, or third party that may elect to take such action associated with the repair and/or removal of the above noted vehicle. It is further understood and agreed that the contract of repair hereby entered into by the undersigned with Burl’s Collision Center may not be assigned or transferred to any other parties or persons without the specific written consent of Burl’s Collision Center, Inc.

I have been advised by this document that all charges must be paid in full before the vehicle can be released. Procuring payment from the insurance company and obtaining lien holder endorsement (if applicable) will be my responsibility; however, Burl’s Collision Center will assist whenever possible to expedite the process. Failure to take delivery of the vehicle more than 3 days after notice of the repair being completed may cause additional charges and storage to accrue at prescribed charges. In the event repairs are halted or terminated prior to completion, storage charges ($65 outside/$85 inside), stall tie up, administrative costs, blueprint labor expense or “BLE” and other incidental charges may be assessed from the date my vehicle arrived to such time as it is removed from Burl’s Collision Center Inc. premises. In the event that the insurance company “denies” the vehicle manufacturers required OEM processes that are necessary in order to replace your vehicle to pre-accident condition, storage will apply from the day it was denied until the beginning of repairs.

By my signature, I confirm that I have thoroughly read, understand and fully agree to the above. For Consideration of repairs to be performed on this vehicle, I hereby Authorize Burl’s Collision Center to sign my name on any insurance draft or check resulting from this claim and to take such actions as to negotiate said payment(s).

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