Repair Contract — Towne Body Shop

1

Customer Information

Your personal contact details

Date *

Customer Name *

Street Address *

City *

State / ZIP *

Email *

Phone *

2

Vehicle Information

The vehicle being repaired

Year *

Make *

Model *

VIN *

Repairs Requested / Nature of Problem *

3

Insurance Information

Your claim details

Insurance Company *

Claim Number *

Claim Adjuster Name

Adjuster Phone

Date of Accident *

Policy Number

Third Party Claim?

Yes No

If Third Party — Was Liability Admitted?

Yes No N/A

4

Motor Vehicle Repair Authorization

Required by Connecticut law — initial to acknowledge

Connecticut law requires that we obtain written authorization before starting repairs on your vehicle. By signing this Repair Contract, you are authorizing Towne Body Shop, Inc. (TBS) to perform repairs on your vehicle and expressly authorize it and its employees to operate the above-listed vehicle on the streets, highways, or elsewhere for the purpose of testing and/or inspection.

Right to Choose Repair Shop: I am aware of my right to choose the licensed repair shop where the damage to the motor vehicle will be repaired.

Initial Here

Initials

5

Customer's Waiver of Advance Estimate

Initial to acknowledge

I authorize Towne Body Shop to perform repairs to my vehicle without a final repair cost estimate in advance. I understand that any initial estimate reflects visible damage only and that additional, non-visible (hidden) damage may be discovered during the teardown and repair process.

If additional damage is identified, Towne Body Shop will prepare a supplemental estimate and submit it to the applicable insurance carrier for review and authorization. I will be notified of any repairs not approved by the insurance carrier before any further work is performed.

Towne Body Shop is authorized to proceed with repairs up to a total amount of $25,000.00. This amount will not be exceeded without prior insurance approval and my written or verbal authorization. No work will be performed without proper authorization, and there will be no hidden or surprise charges.

I have read and understand the waiver of advance estimate.

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Initials

6

Authorization of Additional Repairs

Initial to acknowledge

I understand that quite often additional damage is discovered upon the removal of parts from my vehicle. If additional repairs beyond those originally observed are discovered, I hereby authorize TBS to make the repairs necessary.

I authorize TBS to perform additional repairs as discovered during teardown.

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Initials

7

Completion of Repairs / Retention of Parts

Initial to acknowledge

Repairs to your vehicle will not be completed on the same business day the vehicle is brought in. By signing below, you consent to a later date of completion.

Would you like to keep your replaced parts? (Optional)

Yes, keep my parts No

I understand repairs will not be completed same-day and consent to a later completion date.

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Initials

8

Labor Charges in the Event of a Total Loss

In the event the above vehicle is not repaired by TBS or is deemed a total loss, labor charges at the posted rate will be assessed for any services rendered.

9

Insurance Payment & Labor Rate Responsibility

Initial to acknowledge

I acknowledge and agree that Towne Body Shop's posted labor rate is $90.00 per hour, and that this rate reflects the shop's customary and reasonable charge for repair services performed.

I understand and agree that Towne Body Shop is not a party to any insurance policy, contract, or agreement between myself and my insurance carrier and is not bound by any labor rate limitations, guidelines, or payment determinations imposed by any insurer.

I further acknowledge and agree that authorization of repairs constitutes my acceptance of full financial responsibility for all repair charges incurred, including but not limited to labor, parts, materials, and applicable fees. In the event that my insurance carrier refuses, delays, disputes, or fails to pay Towne Body Shop's full labor rate, I agree that I am personally and immediately responsible for payment of any difference between the amount paid by the insurance carrier and Towne Body Shop's posted labor rate.

I acknowledge that I have been advised of my right to communicate directly with my insurance carrier regarding any labor rate discrepancy, to contest the carrier's payment decision, and to elect whether to proceed with or discontinue repairs based on my potential financial obligation.

I acknowledge the labor rate responsibility and my rights regarding insurance payment decisions.

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Initials

10

Consent to Charge Storage

Initial to acknowledge

I acknowledge that my vehicle was brought to this facility consensually (by my own choice) and that I knowingly and voluntarily agree to pay storage for each day that my vehicle is kept on TBS's premises, regardless of whether the vehicle is repaired or declared a total loss. I acknowledge that TBS has posted daily storage rates.

For vehicles being repaired, storage may be charged for any day that TBS is in possession of your vehicle while it is not being actively repaired. Fees shall begin to accrue on the 3rd day after receipt of the vehicle and 48 hours after notice to you that the repairs have been completed. If your vehicle has been determined a total loss, storage shall be charged for each day the vehicle was present at TBS.

I consent to storage charges as described above.

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Initials

11

Payment

By signing this agreement, you are authorizing the above referenced insurance company to make direct payments to TBS of any and all proceeds and payments related to the above referenced claim for property damage/repair. It is expressly agreed and understood that if any one or more of the property damage payments are sent to you, that you are required to immediately turn them over to TBS.

The above vehicle is being repaired for you, our customer. We may not be able to release your vehicle if we have not received full payment. By signing this Repair Contract, you acknowledge and agree that if you, your insurer or a third-party insurer, fail to pay for services rendered and/or storage fees, interest will be added to the unpaid balance at a rate of 1.5% per month (18% per annum) and you will be responsible for all reasonable attorneys' fees and court costs incurred by the repair shop to collect payment.

12

Possession and Replevin

I agree that TBS shall have a lien against the vehicle for all unpaid services and shall have the right to retain the vehicle until the repair facility is paid in full, as permitted by law. You agree to pay any and all cost and expenses, including reasonable attorneys' fees, our repair facility incurs relating to any action in replevin.

13

Acknowledgement of Pre-Storage

Initial to acknowledge

I acknowledge that I understand the concept of pre-storage charges, Towne Body Shop's policy for enforcing them, and their role in expediting the claims process. I am aware that insurance companies may advise customers that payment of pre-storage charges is their responsibility. I also recognize my right to choose any body shop for repairs and my entitlement to timely vehicle repairs.

I understand that Towne Body Shop's primary goal is not to collect storage fees, but to repair my vehicle as quickly and efficiently as possible. To support a timely repair process, I agree to cooperate, when necessary, in helping Towne Body Shop obtain prompt involvement from the applicable insurance adjuster, including facilitating in-person inspections when required.

Additionally, I confirm that Towne Body Shop has explained its preference for conducting in-person estimates over virtual estimates. I understand that in-person estimates provide a more accurate assessment of the vehicle's condition and repair needs, helping avoid delays and ensuring a thorough and effective repair process.

I acknowledge the pre-storage policy and agree to cooperate with the insurance adjuster process.

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Initials

14

Assignment

By signing this agreement, you are acknowledging that you own, lease, or have rightful possession and the right to exercise authority over the above referenced vehicle. You further acknowledge that you hired TBS to repair said vehicle and you are leaving TBS in possession of your vehicle.

In the event that TBS is not fully compensated for the repairs to your vehicle pursuant to the Repair Order, but in exchange allows you to take your vehicle from its premises before full payment of the repairs and/or TBS gives up its right to keep your vehicle until the repair bill has been paid in full, you are hereby assigning TBS along with its successors and/or assigns, all RIGHTS, BENEFITS, CLAIMS, AND CAUSES OF ACTION, AND/OR ANY PROCEEDS THAT HAVE ACCRUED OR MAY ACCRUE UNDER AN INSURANCE CONTRACT RELATING TO THE CLAIM NUMBER REFERENCED ABOVE FOR REPAIR COSTS TO THE MOTOR VEHICLE, AND THE RIGHT TO SUE IN ITS OWN NAME AND TAKE ALL AVAILABLE LEGAL MEASURES AND ACTIONS, AS IT DEEMS PROPER AND NECESSARY, IN CONNECTION WITH OR RELATED TO PROPERTY DAMAGE INCURRED TO THE VEHICLE THAT WAS SUSTAINED ON THE ACCIDENT DATE LISTED ABOVE. THIS ASSIGNMENT SHALL NOT SERVE TO TRANSFER ANY RIGHTS YOU MIGHT OTHERWISE HAVE UNDER A WARRANTY CLAIM OR FOR ADDITIONAL DAMAGES SUBSEQUENTLY DISCOVERED.

15

Customer Copy & Signature

As the customer, you are entitled to a copy of this Repair Contract. By signing below, you acknowledge receipt of the same.

I sign this document of my own free will and accord.

Customer Signature *

Sign here

Date *

Direction of Pay

Please fill out completely

Repair Facility: TOWNE BODY SHOP, INC. · Tax ID #: 06-0970417

I request and authorize the insurance company listed on this claim to make direct payment to Towne Body Shop, Inc. of any and all proceeds and property damage payments related to the above claim. It is expressly agreed and understood that if any one or more of the property damage payments are sent to me, I am required to immediately turn them over to the repair facility.

My failure to remit any property damage checks or otherwise fail to make full payment for repairs will constitute a breach of my repair contract and result in penalties for non-payment, including the accrual of interest to the unpaid balance at a rate of 1.5% per month (18% per annum) and reasonable attorneys' fees and court costs.

Signature *

Sign here

Date

Amica Mutual Insurance — Repair Assistance Program: Direction to Pay

Amica Mutual Insurance Company · One Hundred Amica Way, Lincoln, Rhode Island 02865

YOU HAVE THE RIGHT TO CHOOSE THE LICENSED REPAIR SHOP WHERE THE DAMAGE TO YOUR MOTOR VEHICLE WILL BE REPAIRED.

Date
—

Claim Number
—

Customer Name
—

Home Phone
—

Address
—

Vehicle
—

VIN
—

I, [Customer Name], am completely satisfied with the workmanship of all repairs and authorize payment on my claim as listed above to:

Shop: Towne Body Shop · 1298 Stratford Ave, Stratford, CT 06615

Authorized Owner's Signature *

Sign here

Date

Witness Signature

Witness signs here

Witness Print Name

Citizens/Hanover Insurance — Express Claims: Authorization for Payment

This form authorizes Hanover to issue payment directly to Towne Body Shop

Repair Shop: Towne Body Shop · Tax ID: 06-0970417 · 1298 Stratford Ave, Stratford CT 06615 · (203) 375-5288

Vehicle Owner's Name
—

Claim Number
—

Policy Number
—

Vehicle
—

Underwriting Company Name (from your appraisal/estimate paperwork)

Insured's Name (if different from you)

This is to certify that the damages estimated or appraised have been repaired to my satisfaction and Citizens/Hanover Insurance Company is hereby authorized to issue payment only in the name of Towne Body Shop. I have received a copy of the appraisal of damages and the final bill.

Vehicle Owner's Signature *

Sign here

Date

Witness Signature

Witness signs here

Witness Date

📧 To Receive Payment: This form will be emailed to ECSHOP@hanover.com or faxed to 888-766-1814 within 48 hours of completion. Towne Body Shop handles this on your behalf.

Plymouth Rock — Direction of Payment

This form authorizes Plymouth Rock to issue payment directly to Towne Body Shop Inc.

Claim Number
—

Customer's Name
—

Vehicle Year and Make
—

Referencing the above captioned claim, I (we) have received a complete copy of the itemized repair estimate indicating all work performed and the costs.

Furthermore, I (we) authorize payment, on my behalf, directly to the repair shop, namely;

Shop Name: Towne Body Shop Inc. · Tax ID: 06-0970417

Customer's Signature *

Sign here

Date

I certify that the above captioned vehicle has been repaired to it's pre-loss condition relative to safety, function and appearance, in accordance with the submitted repairs itemization.

Shop Representative's Signature

— · Towne Body Shop Inc. · Date: —

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, and any person who knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance company, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the value of the subject motor vehicle or stated claim for each violation.

Customer / Self-Pay

Payment terms for out-of-pocket repairs

Payment terms for customer-pay repairs will be discussed with you directly at drop-off. By submitting this form you acknowledge responsibility for the full cost of repairs as agreed.