Authorization to Repair and Receive Payment

We Gladly Accept Cash, Cashiers Check, Money Order, and Insurance Check

Claim Number(Required)

Customer Name(Required)

First Last

Customer Address(Required)

Street Address Address Line 2 City State ZIP Code

Insurance(Required)

Deductible Amount(Required)

Contact Phone(Required)

Contact Email(Required)

Payment(Required)

I agree to the payment terms below.

I/we agree to pay in full for the services described in the estimate upon completion including the deductible amount I selected before the vehicle will be released. I/we agree that LPBS, LLC may need a final payment confirmation from insurance before the release of the vehicle. Please be informed your insurance check may have to be signed by the lien holder. The customer is responsible for acquiring that signature before the vehicle will be released. Any supplemental checks paid by the insurance will need to be provided before the release of your vehicle. Additional charges may be necessary if hidden damage is found. A 3.5% fee will be charged for Credit/Debit cards.

Parts and Availability(Required)

I agree to the parts and availability terms below.

I understand that a completion date may change because of availability of parts. I understand availability of parts is not under LPBS, LLC control. Selection of OEM parts will be approved by your insurance carrier based on the coverage you selected. LPBS, LLC is not at liberty to select or approve parts. Repairs and estimates will be completed using manufacturer specified repair protocol and best practice standards using OEM and Aftermarket, Like, Kind and Quality parts.

Betterment(Required)

I agree to the betterment terms below.

I acknowledge I may be required to pay a Betterment on wear and tear items. A Betterment is a provision which stipulates that if replacement of damaged wear and tear parts results in better than “like kind or quality” the insurers will not pay the total of the new part. The customer may have to pay a percentage of the part.

Pick Up(Required)

I agree to the pick up terms below.

Unless prior arrangements have been made, I agree to pick up vehicle within TWO business days of completion otherwise charges may be incurred due to storing the vehicle.

Direction to Pay(Required)

I agree to the direction to pay terms below.

If any payments from the insurance carrier come to myself in error, I will release that payment to LPBS, LLC and provide my signature on the check if required for deposit. I understand that I may request any payments be made directly to LPBS, LLC to expedite the payment process.

Personal Belonging(Required)

I agree to the direction to personal belongings terms below.

I acknowledge that LPBS, LLC is not responsible for personal belongings left in my vehicle.

Personal Method Agreement(Required)

I agree to the direction to payment method agreement below.

Attention customers:
Your deductible and insurance payment will be due in full at the completion of vehicle. Cars can’t be released without payment.
Lindley’s paint and body accepts the following forms of payment:

insurance check signed by customer
cash
cashiers check
money order

NO PERSONAL CHECKS, DEBIT OR CREDIT CARDS
VEHICLE CAN NOT BE PICKED UP UNLESS INSURANCE HAS CONFIRMED FINAL PAYMENT

Signature(Required)

By signing and submitting this form, you understand and agree that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement.