Customer informationFull name Email* Phone NumberResponsible Insurance Company Claim Number Vehicle InformationYear Make Model Rental VehicleDo you need a Loaner Vehicle? Yes No Direction of Pay I hereby authorize and direct the Insurance Company listed above to pay Total Recon directly for the repair work, including, but not limited to, parts and labor covered by insurance. In the event for any reason payment should come directly to me, I hereby agree to pay Total Recon within twenty-four (24) hours of my receipt of the payment from the Insurance Company. I fully understand and agree that I am personally liable for any and all deductibles, depreciation, labor, parts, or any other charges or costs not covered by insurance. I agree to pay Total Recon for any amount not covered by insurance. This Direction to Pay shall be governed by the laws of the State of Maryland. The parties agree that in the event of any legal action arising out of or relating to the Direction to Pay, including any action brought to enforce the terms of the Direction to Pay, must be brought exclusively in the Circuit Court or District Court for Montgomery County, Maryland, as applicable, and the parties consent to the exclusive jurisdiction and venue of these Courts to enforce the terms of the Direction to Pay. The parties expressly waive the right to transfer any action filed therein. In the event of any legal action arising out of or relating to the Direction to Pay, Total Recon shall be entitled to recover all costs and expenses, including reasonable attorneys’ fees, incurred in enforcing, attempting to enforce, or defending such action, including costs incurred prior to commencement of legal action and in any appeal. Customer’s Rights With my signature below, I hereby authorize Total Recon to perform repair work on the motor vehicle listed above (“Vehicle”). I understand that I may request a written estimate for repairs which cost in excess of $25.00. Further, I understand that I may not be charged, without my consent, any amount which exceeds the written estimate by ten percent (10%). I understand that I am entitled to receive the return of any replaced parts, except for replaced parts that are required to be returned to the manufacturer or distributor under a warranty agreement. By not checking the following box I understand the old parts will not be returned to me. By agreeing to this authorization form, I understand that the old parts will not be returned to me. I also understand that repairs not originally authorized or requested by me may not be charged to me without my consent. While the Vehicle is on Total Recon premises, Total Recon is not responsible for the loss or damage to my Vehicle or the contents or articles left in the Vehicle as a result of a fire, theft, accident or any other cause. I understand I have the right to ask a Total Recon representative about the extent of Total Recon’s responsibility, including the extent of the insurance coverage of Total Recon. Further, I authorize Total Recon and its employees to operate the Vehicle for the purpose of road testing and/or inspecting the Vehicle. Total Recon is not responsible for the unavailability of parts, or delays in part shipments. I acknowledge that in the event that I fail to pick up my Vehicle within forty-eight (48) hours of being notified that it is ready to be picked up, storage fees may apply in the amount of $95.00 per day. I acknowledge and agree that if I should request that repair work be stopped at any time on the Vehicle, I will be solely responsible for the costs of any and all repair work completed to that point, as well as the cost of the parts which are not returnable, or restocking fees charged to Total Recon, if I choose not to purchase the parts. This Authorization to Repair shall be governed by the laws of the State of Maryland. The parties agree that in the event of any legal action arising out of or relating to the Authorization to Repair, including any action brought to enforce the terms of the Authorization to Repair, must be brought exclusively in the Circuit Court or District Court for Montgomery County, Maryland, as applicable, and the parties consent to the exclusive jurisdiction and venue of these Courts to enforce the terms of the Authorization to Repair. The parties expressly waive the right to transfer any action filed therein. In the event of any legal action arising out of or relating to the Authorization to Repair, Total Recon shall be entitled to recover all costs and expenses, including reasonable attorneys’ fees, incurred in enforcing, attempting to enforce, or defending such action, including costs incurred prior to commencement of legal action and in any appeal. Manufacturer Special Policy Adjustment Programs Federal law requires manufacturers to furnish the National Highway Traffic Safety Administration (N.H.T.S.A.) with bulletins describing any defects in their vehicles. You may obtain copies of these bulletins either from the manufacturer or N.H.T.S.A. In addition, certain consumer publications or organizations publish this information, which may be available for a fee or for free.If you would like to retain your parts please check the following box. By checking the following box you are agreeing to take all of the damaged parts from the shop at the completion of your repair. You cannot select specific parts to retain. Retain parts Signature (By signing below, I hereby acknowledge and agree that I have read and understand the Authorization to Repair, Consumer Right’s and Direction of Pay stated herein. Any difference in labor rates not covered by the insurance company held liable adhering to Tesla's set rates will be customer's responsibility.* Δ
Customer informationFull name Email* Phone NumberResponsible Insurance Company Claim Number Vehicle InformationYear Make Model Rental VehicleDo you need a Loaner Vehicle? Yes No Direction of Pay I hereby authorize and direct the Insurance Company listed above to pay Total Recon directly for the repair work, including, but not limited to, parts and labor covered by insurance. In the event for any reason payment should come directly to me, I hereby agree to pay Total Recon within twenty-four (24) hours of my receipt of the payment from the Insurance Company. I fully understand and agree that I am personally liable for any and all deductibles, depreciation, labor, parts, or any other charges or costs not covered by insurance. I agree to pay Total Recon for any amount not covered by insurance. This Direction to Pay shall be governed by the laws of the State of Maryland. The parties agree that in the event of any legal action arising out of or relating to the Direction to Pay, including any action brought to enforce the terms of the Direction to Pay, must be brought exclusively in the Circuit Court or District Court for Montgomery County, Maryland, as applicable, and the parties consent to the exclusive jurisdiction and venue of these Courts to enforce the terms of the Direction to Pay. The parties expressly waive the right to transfer any action filed therein. In the event of any legal action arising out of or relating to the Direction to Pay, Total Recon shall be entitled to recover all costs and expenses, including reasonable attorneys’ fees, incurred in enforcing, attempting to enforce, or defending such action, including costs incurred prior to commencement of legal action and in any appeal. Customer’s Rights With my signature below, I hereby authorize Total Recon to perform repair work on the motor vehicle listed above (“Vehicle”). I understand that I may request a written estimate for repairs which cost in excess of $25.00. Further, I understand that I may not be charged, without my consent, any amount which exceeds the written estimate by ten percent (10%). I understand that I am entitled to receive the return of any replaced parts, except for replaced parts that are required to be returned to the manufacturer or distributor under a warranty agreement. By not checking the following box I understand the old parts will not be returned to me. By agreeing to this authorization form, I understand that the old parts will not be returned to me. I also understand that repairs not originally authorized or requested by me may not be charged to me without my consent. While the Vehicle is on Total Recon premises, Total Recon is not responsible for the loss or damage to my Vehicle or the contents or articles left in the Vehicle as a result of a fire, theft, accident or any other cause. I understand I have the right to ask a Total Recon representative about the extent of Total Recon’s responsibility, including the extent of the insurance coverage of Total Recon. Further, I authorize Total Recon and its employees to operate the Vehicle for the purpose of road testing and/or inspecting the Vehicle. Total Recon is not responsible for the unavailability of parts, or delays in part shipments. I acknowledge that in the event that I fail to pick up my Vehicle within forty-eight (48) hours of being notified that it is ready to be picked up, storage fees may apply in the amount of $95.00 per day. I acknowledge and agree that if I should request that repair work be stopped at any time on the Vehicle, I will be solely responsible for the costs of any and all repair work completed to that point, as well as the cost of the parts which are not returnable, or restocking fees charged to Total Recon, if I choose not to purchase the parts. This Authorization to Repair shall be governed by the laws of the State of Maryland. The parties agree that in the event of any legal action arising out of or relating to the Authorization to Repair, including any action brought to enforce the terms of the Authorization to Repair, must be brought exclusively in the Circuit Court or District Court for Montgomery County, Maryland, as applicable, and the parties consent to the exclusive jurisdiction and venue of these Courts to enforce the terms of the Authorization to Repair. The parties expressly waive the right to transfer any action filed therein. In the event of any legal action arising out of or relating to the Authorization to Repair, Total Recon shall be entitled to recover all costs and expenses, including reasonable attorneys’ fees, incurred in enforcing, attempting to enforce, or defending such action, including costs incurred prior to commencement of legal action and in any appeal. Manufacturer Special Policy Adjustment Programs Federal law requires manufacturers to furnish the National Highway Traffic Safety Administration (N.H.T.S.A.) with bulletins describing any defects in their vehicles. You may obtain copies of these bulletins either from the manufacturer or N.H.T.S.A. In addition, certain consumer publications or organizations publish this information, which may be available for a fee or for free.If you would like to retain your parts please check the following box. By checking the following box you are agreeing to take all of the damaged parts from the shop at the completion of your repair. You cannot select specific parts to retain. Retain parts Signature (By signing below, I hereby acknowledge and agree that I have read and understand the Authorization to Repair, Consumer Right’s and Direction of Pay stated herein. Any difference in labor rates not covered by the insurance company held liable adhering to Tesla's set rates will be customer's responsibility.* Δ