Authorization

Complete our online authorization form to get your repair started quickly and conveniently. This form grants us permission to perform the necessary repairs on your vehicle.

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Call Now: (786) 901-9704
Language / Idioma
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Fill out the form below — you'll sign in 4 places

Type directly. The invoice preview below updates as you type. All 4 signatures are required to submit.

Customer Information

Your Details

Vehicle Details

Insurance Information (Required if using insurance)

County Required

After reviewing the information below, please sign the signature fields. To change or correct information, edit the form above.

Please Read Carefully, Check One of the Statements Below, and Sign:

I understand that, under state law, I am entitled to a written estimate if my final bill will exceed $150.

THE SHOP MAY NOT EXCEED THIS AMOUNT WITHOUT MY WRITTEN OR ORAL APPROVAL.

1
Signature
Date:Jun 17, 2026
PSG Paint & Body Shop

COMPANY INVOICE

MV:68178
MVR:91306
Address:2099 NE 160th St, North Miami Beach, FL 33162
Phone Number:(786) 901-9704
Name: 
Address: 
City: 
State: 
Zip: 
Phone: 
Date:Jun 17, 2026
X  INVOICEX  ESTIMATE
* U/Used R/Repaired A/Aftermarket S/Straightened
LABOR HOURS
QTY*PartDescriptionBodyPaintFrameMech
   
CUSTOMER COMPLAINT/PROBLEM:
    
   CLAIM #:     
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        

All parts and labor are warrantied for months / miles unless otherwise stated.

Vehicle Information
VIN: 
Yr/Make: 
Model: 
Save Parts:

Core may apply

Charges based on:

Estimate Diagnosis:

or

/hr.

Payment Method:

Estimated Cost: $

**This charge represents costs and profits to the motor vehicle repair facility for miscellaneous shop supplies or waste disposal.

***s. 403.718, F.S. mandates a $1.50 fee for each new or manufactured battery sold in the State of Florida.

Estimate good for 30 days. The facility is not responsible for damage caused by theft, fire, or acts of nature. I authorize the above repairs to my vehicle including the necessary materials and sublet work. You and your employees may operate my vehicle for the purpose of testing, inspection, and delivery at my risk. If I cancel repairs to my vehicle for any reason, I understand that a tear-down and reassemble fee of $300 will apply. I understand that a charge of $150 per day will be charged if I fail to pick up my vehicle within (3) working days of notification of completion.

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Signature
Date:Jun 17, 2026
Body Hours/@$60Parts:$
Paint Hours/@$60Labor:$
Mech Hours/@$210**Shop Sup:$
Paint Supplies$40Sublet:$
Body Supplies$40***Fees:$
Tow Storage:$150/105Subtotal:$
Epa/Waste$55Tax:$
Miscellaneous$Total:$
Repair Agreements

PSG Paint & Body Shop

VEHICLE REPAIR AUTHORIZATION AND CUSTOMER AGREEMENT

Customer Authorization and Agreement

I, the undersigned, authorize the repair work on my vehicle, as specified, to be performed by PSG Paint & Body Shop ("the Repair Shop"). I understand and accept the following terms and conditions regarding the repair and payment of my vehicle.

Care, Custody, and Protection (CCP) Fee

A Care, Custody, and Protection (CCP) Fee will be charged as follows:

  • $150 per day for vehicles stored inside
  • $105 per day for vehicles stored outside

These charges begin on the day the vehicle is dropped off at the Repair Shop. In the event that the vehicle is deemed a total loss, this CCP fee will apply from the date of drop-off until the date of removal by the customer or their insurance provider.

Authorization for Parts and Cancellation Terms

I authorize the Repair Shop to order necessary parts for repairs. Should I cancel the repairs after parts have been ordered, I agree to the following:

  • Restocking Fee: A 30% restocking fee will apply to all parts ordered.
  • Non-Returnable Parts: If any part ordered is non-returnable due to its status as an electronic or special order, I agree to pay for the part in full, and that part will be provided to me.

Repair Agreement

  • The Repair Shop is not responsible for loss or damage to my vehicle, or any articles left in the vehicle, due to fire, theft, or any cause beyond its control.
  • I grant permission to the Repair Shop and its employees to operate my vehicle on streets, highways, or elsewhere as necessary for testing and/or inspection.
  • An express mechanic's lien is hereby acknowledged on the above-described vehicle to secure payment for all repair work done.
  • Old Parts: Old parts removed and replaced will be discarded unless otherwise specified by me before repairs begin.

Payment and Insurance Responsibilities

All repair costs, including deductibles and any customer-paid expenses, must be settled in full before the vehicle is released. If my insurance issues a direct payment to me instead of the Repair Shop, I acknowledge that I am solely responsible for paying any outstanding balance.

If repairs are canceled or partially completed, the Repair Shop may charge for teardown costs, parts ordered, and any labor required to reassemble the vehicle.

Assignment of Benefits

By my signature below, I hereby assign, transfer and convey to PSG Paint & Body Shop (hereinafter "Provider"), all of my rights, title and interest in and to auto repair reimbursement in whatever form, including but not limited to any insurance coverage under property damage, comprehensive, collision, windshield and/or any coverage otherwise payable to me through auto insurance. This payment shall not exceed any indebtedness to the above named assignee and I acknowledge that I will timely pay any indebtedness owed by me to the assignee that is not otherwise satisfied by the above-mentioned assigned proceeds.

I further authorize the Provider to negotiate, collect and settle any claim with any insurance carrier or other third party payor with regard to these services. The Provider has the authority to: (1) request and receive from any insurer documentation and records regarding this claim, and (2) endorse in my name any check issued for payment where benefits were assigned.

The Provider hereby objects to any reductions or partial payments. Any partial or reduced payment shall be deposited under protest, at the risk of the insurer.

THIS IS A DIRECT AND IRREVOCABLE ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER MY POLICY OF INSURANCE.

A digital copy of this form shall be considered as effective and valid as the original.

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Assignment of Benefits Signature

Required — this is a separate legal assignment of your insurance rights.

Date: Jun 17, 2026

E-Sign Consent

Consent to Electronic Communications & Signatures

I authorize PSG Paint & Body Shop, to contact me about my repair via phone, email, or text message and agree to any data rates that may apply. I may opt out of communications at any time.

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Final Signature

This is your final E-Sign consent.

Sign to complete authorizationDate: Jun 17, 2026