Dent Connect Service agreement

Please fill out the form below to officially start your repairs

Customer Information

First name *

Last name *

Email *

Phone number *

Street Address *

City *

State *

Zip Code *

Insurance Information

Insurance Company *

Policy Number *

Claim Number *

Adjuster Name *

Adjuster Email

Adjuster Phone Number

Deductible Amount *

Date Of Loss *

Insurance Information Notes *

Vehicle Information

Year *

Color *

Make *

Model *

License Plate Number *

VIN Number *

Please Note any prior damage to the front, rear, left, right, and top of vehicle *

Rental Information

Check this box if you have rental car coverage

What's the Coverage rate?

Check this box if you need a rental car

What's the rate?

Date In:

Gas:

Digital Signature *

Dent Connect covers the daily rental fee and taxes when not covered by insurance. Gas, tolls, damages, fines, tickets etc. are the responsibility of the driver on rental agreement.

Finalization

Agreement Digital Signature *

Date *

I hereby certify that I have the legal right to authorize repairs for the above listed vehicle, either through legal ownership, lease rights, or authorization from the vehicles owner. I hereby authorize the repair work to be completed to my vehicle along with the necessary materials after approval from my insurance carrier. I agree that Dent Connect shall not be responsible for any loss or any damage to my vehicle, or articles left therein, in case of fire, theft, or any cause or for delays related to the repair of my vehicle beyond its control. I hereby grant permission to Dent Connect, its employees, and agents to operate my vehicle for delivery,inspection and testing. If after further examination, additional repairs are necessary, I or my insurance will be contacted for authorization of any additional repair charges. In the event new parts listed in the estimate are not available or repairable, I authorize Dent Connect to manufacture access to dents that may not be accessible to due their location on my vehicle. Unless otherwise directed, old parts will be thrown away. I understand that Dent Connect at their discretion; may convert a panel or panels from conventional or replace to paintless dent repair; convert panel or panels from paintless dent repair to conventional or replace. All amounts due for the repair charges must be paid prior to the release of your vehicle. Please be certain all payees, including lien holders have endorsed the check prior to the release of the above repaired vehicle. I hereby authorize my insurance carrier to pay Dent Connect directly for all supplement amount towards the repairs made to my vehicle. I hereby authorize Dent Connect to act as power of attorney to sign or endorse any check/draft made payable to me as a settlement for my claim if needed. An expressed mechanics lien is hereby acknowledged on the above vehicle should the need occur to secure the amount of remaining balance due.Dent Connect is not responsible for any prior damage to your vehicle, photographs are taken during check-in or by your insurance carrier for verification. In the event I remove my vehicle from the repair facility, I agree to pay for the work completed, handling fees, and service charges. Dent Connect warrants the repairs performed to the above vehicle under a limited lifetime warranty from the date the vehicle is release, relating to the currentloss.

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