GST/HST #: 737613521

PST #: 1224381626

COLLISION
AUTOLUX MB COLLISION INC CENTRES AUTH
FORM
8305 BOUL SAINT-LAURENT RO# 4583
MONTREAL, QC H2P 2M7
(514) 387-7133, (514) 381-9703 Fax
22 Mercedes-Benz GLC43
RAFIC BADRAN Color: WAWANESA
849 RUE MELANIE Type: UV 4 Door Utility Adjustor: GAEL
LAVAL, QC H7X 3V3 VIN: W1N0G6EBXNV376832 COURCIMAULT
Home: Prod Date: Plate: G72ZCC Phone:
Work: Odometer: 1 Claim #: 1032611 Deductible: 0
Cell: 514-924-8992 Engine: 3.0L 6 Cyl Gas Injected Loss Type:
Turbocharged
The undersigned (hereinafter referred to as "I", "My", "Myself") hereby authorize AutoLux MB Collision also known
as AutoLux MB Collision (hereinafter referred to as the "Collision Centre") to make the repairs as specified on the
work order identified by the Claim No. above (the "Repairs"). I hereby grant the Collision Centre's employees
permission to operate the vehicle on streets, highways, or elsewhere for the purposes of testing and/or inspection.
An express mechanics/garage keeper's lien is hereby agreed to on the vehicle to secure the cost of the Repairs.
The Collision Centre will dispose of old parts removed from the vehicle unless otherwise instructed by myself or
my insurer.

The Collision Centre will not be held responsible for loss or damage to my vehicle or articles left in my vehicle in
the case of fire, theft, accident, or any other cause not due to the negligence of the Collision Centre and its
employees. Once I am advised that the vehicle is ready for pick-up, I acknowledge that I have 24 hours to bring
back the rental vehicle if one has been provided by the Collision Centre and failing which, after such time, I will be
charged for rental fees and irrevocably expressly permit the Collision Centre to repossess the rental vehicle at any
place and time, even if it is located on my property at the time of repossession (if applicable).
POWER OF ATTORNEY
I hereby appoint the Collision Centre to act as my lawful attorney-in-fact exercisable should the Collision Centre
receive and to accept on my behalf any and all cheques, drafts, or bills of exchange from my insurance company
and to endorse all such cheques, drafts, bills of exchange for deposit to the Collision Centre's account for credit
towards the cost of the Repairs. I hereby appoint the Collision Centre to act as my lawful attorney-in-fact to
authorize my insurer to make any and all supplemental charges relating to the Repairs to be made directly payable
to the Collision Centre.
VEHICLE RELEASE POLICY
· All repairs must be paid in full prior to release of the vehicle (unless prior arrangements have been made).
· All insurance deductible amounts & sales tax (as applicable) are payable to the Collision Centre.
· I acknowledge having been given an opportunity to read and ask questions regarding this Vehicle Release
Policy and I have either done or so or, chosen not to and hereby waive the opportunity to have done so,
and thereby acknowledge having read and understood the Vehicle Release Policy.
· I understand that an estimated delivery/pick-up date is not guaranteed and is subject to change.
· I understand that if I cancel the repairs after parts have been ordered, I will be responsible for any
restocking fees, if applicable.
· I recognize that I am responsible for all deductibles, sales tax and betterment amounts, which must be
paid prior to the Collision Centre releasing the vehicle.
· If liability for my insurance deductible is unclear when the vehicle is ready to be picked up, I agree to pay
the deductible to the Collision Centre and to pursue my Insurance company for reimbursement.

Signature: ________________________________ Date: 05/15/2024

________________________________

ralphb1989@gmail.com
Email: _________________________________

COLLISION CENTRES AUTH FORM #500 5/15/2024 10:11 AM RO# 4583 AUTOLUX MB COLLISION INC
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