Please enable JavaScript in your browser to complete this form.Aiken Collision, Inc. 727 Richland Avenue East, Aiken, SC 29801 PH: 803-226-0270 | Email: info@aikencollision.com DIRECT PAYMENT & AUTHORIZATION TO REPAIR Name *FirstLastDate *Phone *Email *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeYear *Make *Model *VIN *ColorI, the undersigned, hereby authorize Aiken Collision, Inc and its employees to perform a complete disassembly of the damaged components so that an estimate may be written for the repair of my vehicle, to drive my vehicle for testing and/or inspection. I understand that Aiken Collision, Inc will not be held responsible for theft of or from my vehicle or missing articles left in the vehicle. Please remove all items from your vehicle before leaving the vehicle for repair. I understand that Aiken Collision, Inc is unable to release any vehicle without full payment. I agree to pay Aiken Collision, Inc in full for the repairs of my vehicle, either before or after completion of work. I understand that as the owner of the vehicle I am responsible for all charges incurred for the repair. **I authorize the Insurance Company to pay Aiken Collision, Inc. I understand that I am responsible for any difference/overages not covered by insurance payment. INITIAL HERE * Clear Signature A 5% convenience fee will be added to all credit/debit card transactions. We do not accept personal checks. Signature * Clear Signature Date *Submit6131
