Lifetime Warranty by PDRTX: Guaranteed Quality in Celina, TX

repair order/Direction of payment form

Representative Name

Estimate Date *

Customer Info

First Name *

Last Name *

Cell Phone Number

Work Phone Number

Home Phone Number

Home Address (Street City, State, Zip)

Driver's License No.

State Issued

Exp. Date *

Rental Car Needed?

Rental Car Coverage On Insurance Policy?

Vehicle Information

Vehicle Color

Vehicle Make

Vehicle Year

Vehicle Model

Vehicle Trim

License Plate No.

Vehicle VIN

Insurance Information

Auto Insurance Company *

Deductible Amount

Policy Number

Claim Number

Adjuster's Name

Adjuster's Phone Number

Adjuster's Email

Adjuster's Fax Number

Remarks

Damage Type

Hood Damage

Front Cowl Panel Damage

Roof Damage

Rear Cowl panel Damage

Decklid / tailgate Damage

Left fender Damage

left front door Damage

Left rear door Damage

left roof rail / sail panel Damage

Left quarter panel Damage

right fender Damage

Right front door Damage

Right Rear door Damage

Right roof rail / sail panel Damage

Right quarter panel Damage

Remove / install headlines

Remove / install sunroof

Upload Images (if needed):

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TOTAL:

Remarks

Prior Damage Description (If Damaged)

Authorization: I authorize for this to serve as my direction of pay and grant the company permission to get paid for repairs. I agreethat PDRTX Inc. is not responsible for loss or damage to this vehicle and/or articles left in the vehicle due to fire, theft,or any other causes beyond its control. I also hereby grant permission to this company's employees to operate thevehicle for the purpose of testing and/or inspection. Further, I acknowledge that if closer analysis reveals additionalrepairs are necessary, either I or my insurance company will be contacted for authorization of any additional repaircharges. If new parts listed in the attached repair order are not available, I authorize PDRTX Inc. To repair suchdamaged or worn parts when possible. Old parts will be thrown away unless otherwise instructed. PDRTX Inc.authorize to manufacture access to dents that may not be accessible due to their location on the vehicle. The totalamount of repair charges must be paid before the attached vehicle can be released for delivery. If the insurancecoverage pays either a portion of or total amount due, I acknowledge that the insurance check/draft must beobtained by me or sent in advance to the insurance company. I also acknowledge that I must make arrangements withmy lien holder or other payees to endorse the insurance check and/or draft prior to the release of the above repairedvehicle. I authorize any and all supplements payable to PDRTX Inc. for all consideration of repairs to the vehicle. Ihereby authorize PDRTX Inc. to act as power of attorney to sign or endorse any checks and/or drafts made payableto me and any release there to, as settlement for any claim for damage to this vehicle. PDRTX Inc. Is not responsiblefor prior damage listed on the vehicle diagram to the left. To secure payment in amount of repairs, an expressedmechanics lien on the vehicle is acknowledged and I further agree to pay reasonable attorney's fees and court costsin the event that legal action becomes necessary to enforce this contract.

Thank you! Your submission has been received! For your privacy and financial safety, we do not submit credit card or check information through our online forms. After submitting this form, contact us at (469) 885-3796 so we can collect your card information over the phone.

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