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Customer Pay
AAA Allstate American Access American Family Amica Bristol West CEI Chubb Connect Dairyland EasyCare Elephant Falcon Farmers Fred Loya GEICO Germania Hartford Hochheim Infinity Kemper LYNX Liberty Mutual Mercury Nationwide Other Progressive Root Safeco State Farm Tesla Texas Farm Bureau Travelers USAA United Automobile Zurich
Received First Insurance Check?
Yes
No
Number of people in vehicle at the time of accident?
0
1
2
3
4
5
6
7
8+
Clicking the boxes indicates you have read and agree to the following statement(s):
Optimum Collision Lawton is not responsible for loss or damage to vehicles, articles, or personal property left in vehicles, in case of fire, theft, natural disasters or any other cause beyond our control. Please remove all personal belongings from your vehicle.
Vehicles that have sustained extensive damage could require more time to repair and exceed your rental coverage. Optimum Collision Lawton will not be responsible for any rental expense in the event this occurs.
NOTICE PURSUANT TO APPLICABLE OKLAHOMA LAW
Customer understands that this vehicle is subject to repossession in accordance with the relevant provisions of the Oklahoma Uniform Commercial Code (UCC) and any other applicable Oklahoma statutes, if a written order of payment for repairs of the vehicle is stopped, or dishonored because of insufficient funds, no funds, or because the drawer or maker of the order has no account or the account on which it is drawn has been closed.
Authorization to Access Vehicle Data: I understand that modern vehicles are complex and that electronic data recorded in vehicle systems may help to diagnose necessary repairs and to confirm that applicable systems are functional after repairs are performed. I authorize Optimum Collision Lawton to access this data as part of the diagnostic and repair process.
I authorize Optimum Collision Lawton to complete estimated repair work to be done along with the necessary materials. And hereby grant you, and/or your employees' permission to operate the vehicle herein described on streets, highways or elsewhere for the purpose of completing repairs, testing and/or inspection. An express mechanic's lien is hereby acknowledged on above vehicle to secure the amount of repairs thereto.
I understand that signing the following document I give Optimum Collision Center temporary Power of Attorney effective for 180 days from sign date to; Endorse insurance checks on my behalf in relation to services rendered on my vehicle.
