Customer Acceptance Form

Work Authorization

I authorize Putnam Chrysler Dodge Jeep Kia, Inc. to repair my vehicle for the amount agreed upon. I understand that a supplement may be required and as long as the insurance company and you come to an agreement, you have my authorization to proceed. If there is additional cost that will have to be paid myself, other than my deductible if applicable, I must be notified.

I also grant permission for the employees of Putnam Chrysler Dodge Jeep Kia, Inc. to operate my vehicle for the purpose of testing, inspection, or delivery at my own risk. An express mechanics lien is acknowledged on the above vehicle to secure the amount of repairs thereto. It is understood that Putnam Chrysler Dodge Jeep Kia, Inc. will not be held responsible for loss or damage to my vehicle and or loss of articles left in the vehicle caused by fire, theft, or any other cause beyond our control, or for delays caused by the unavailability of parts or shipping delays.

Disclosure Statement

House Bill #5152 of the Connecticut State Insurance Law provides that “You have the right to choose the licensed repair shop where the damage to your motor vehicle will be repaired.” And the insurance carrier shall not require that repairs be made in a particular place or by a particular concern. The law further provides that the insurance company shall not recommend or suggest repairs be made in a particular shop or by a particular concern, unless expressly requested by you.

Direction of Payment

I authorize my insurance company to make direct payment to Putnam Chrysler Dodge Jeep Kia, Inc. on my behalf in the amount specified below. Federal ID #061694157