Vic Jenkins

Local: (615) 452-3037
Toll Free: 888-640-1004

Sales Hours: Monday-Friday 8AM-6PM | Closed Saturday & Sunday

Rental | Service | Bodyshop | Parts Hours: M-F 8AM-5PM

Authorization to Repair and Promise of Payment, Direction to Pay, Power of Attorney

Authorization to Repair and Promise of Payment

I hereby authorize the repair work herein set forth to be done along with the necessary material and agree that Vic Jenkins Auto is not responsible for loss or damage to vehicle or articles left in the vehicle in case of fire, theft or any other causes beyond your control or for any delays caused by unavailability of parts or delays in parts shipments by the supplier or transporter and or delays caused by insurance companies and their procedures. I hereby grant you and/or your employee's permission to operate the vehicle herein described on streets, highways, or elsewhere for the purpose of testing and/or inspection. I fully understand that I am completely responsible for any and all damages that were not paid by insurance company or any other parties that may be involved. I understand that my vehicle may be released to me without payment in full and that I am totally responsible for any bills in the future left unpaid by the insurance company involved or other responsible party. In the even any action is necessary to collect monies and under this promise of payment, I understand that I will be responsible for all cost collection including a reasonable attorney's fee. An express mechanic's lien is hereby acknowledged on below vehicle to secure the amount of repairs thereto.

Full legal name
Today's date in MM/DD/YYYY format

Direction to Pay / Power of Attorney

I do hereby appoint the aforementioned business as my attorney in fact to accept on my behalf any and all checks, drafts, or bills of exchange and to endorse all such checks, drafts, or bills of exchange for deposit to the aforementioned business account for credit on my account for repairs on my vehicle, which has been released and Accepted.

Full legal name
Today's date in MM/DD/YYYY format

Customer and Vehicle Information

Customer Information

Full legal name
Primary phone number
Night phone number (optional)
Address of your primary residence
Address of your primary residence
Address of your primary residence
Address of your primary residence

Vehicle Information

Your vehicle's VIN (Vehicle Identification Number)
Your vehicle's production date in MM/DD/YYYY format
Your vehicle's make (e.g. Toyota, Chrysler, Dodge, RAM, etc)
Your vehicle's model (e.g. Town & Country, Prius, F150, etc)
Your vehicle's mileage
Your vehicle's color
Your vehicle's License Plate

Insurance Information

Your official insurance company
Your insurance agent
Your claim number
Your deductible
Your insurance Adjuster
Insurance Phone Number
Insurance Phone Number (2, Optional)

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