Vehicle Repair Intake Form CommentsThis field is for validation purposes and should be left unchanged.Name(Required) First Name Last Name Mobile Phone(Required)Email(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Vehicle's Year(Required)Select Vehicle Year2026202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001998199819971995Vehicle's Make(Required)Select Vehicle MakeAcuraAlfa RomeoAston MartinAudiBentleyBMWBuickCadillacChevroletChryslerDodgeFerrariFiatFordGenesisGMCHondaHummerHyundaiInfinitiJaguarJeepKiaLamborghiniLand RoverLexusLincolnLucidMaseratiMazdaMcLarenMercedes-BenzMercuryMINIMitsubishiNissanPolestarPontiacPorscheRamRivianRolls-RoyceSaabSaturnScionSubaruTeslaToyotaVolkswagenVolvoOtherVehicle's Model(Required)Date of Loss Insurance Company(Required)Choose from DropdownAcuityAllstateAmerican Family InsuranceBristol WestChubbCountry FinancialDairylandEsuranceFarmersGeicoThe GeneralLiberty MutualNational GeneralNationwideProgressiveSafecoSedgwickState FarmTravelersUSAAWestfieldOtherOther Insurance CompanyDon't see your insurance carrier listed? Please provide the company name below.Claim NumberDeductible(Required)We waive insurance deductibles up to $1,000. Do you need a rental vehicle while your vehicle is being repaired?(Required) Yes No Does your insurance policy include rental vehicle coverage?(Required)We provide you with a complimentary rental vehicle if you do not have coverage. Yes No Service Communications Authorization(Required) I agree to receive communications from Elevated Hail Repair related to my requested services, including scheduling, appointment reminders, repair status, vehicle updates, insurance or claim-related matters, and other communications necessary to manage my repair. Communications may be sent by phone, email, or text message, including through automated systems. Message and data rates may apply.Work Authorization & Direction of Pay Agreement(Required)As evidenced by my signature below, I hereby authorize Elevated Hail Repair and its affiliates to perform the authorized repairs to my vehicle upon receiving approval from my insurance company and to receive payment directly from my insurance company for such repairs. I also grant permission to Elevated Hail Repair, its employees, agents, contractors, and subcontractors to operate my vehicle as reasonably necessary for repair, delivery, testing, and inspection. I acknowledge that if closer analysis reveals additional repairs are necessary, I and/or my insurance company, as applicable, will be contacted regarding authorization for additional repair charges. If new parts are listed in my insurance company’s repair order and either (a) such parts are not timely available or (b) Elevated Hail Repair is able to repair the damaged parts through paintless dent repair, conventional repair, or a combination thereof, I authorize Elevated Hail Repair to repair such damaged parts or, alternatively, utilize new, used, or aftermarket replacement parts in its sole discretion. Old parts may be stored, discarded, or recycled by Elevated Hail Repair. I authorize Elevated Hail Repair to create access to dents that may not otherwise be accessible by removing and replacing parts or creating access points to the vehicle. Elevated Hail Repair may determine the appropriate method of repair, including paintless dent repair, conventional repair, replacement, or refinishing. I further authorize Elevated Hail Repair, in its sole discretion, to subcontract with third parties for the repair of my vehicle, including, without limitation, one or more body shops for conventional repair, replacement, or refinishing work. I authorize Elevated Hail Repair and its authorized representatives to drive or otherwise transport my vehicle to and from such third-party facilities as reasonably necessary to complete the authorized repairs. All repair charges must be paid in full before my vehicle is released. If my insurance company sends payment to me for repairs performed by Elevated Hail Repair, I agree to promptly endorse and deliver the payment to Elevated Hail Repair. I authorize Elevated Hail Repair to endorse and deposit any insurance check or draft made payable jointly to me and Elevated Hail Repair for payment of authorized repairs. I agree to cooperate in obtaining any required lienholder or additional payee endorsements. Elevated Hail Repair provides free estimates. However, if I authorize Elevated Hail Repair to prepare and submit an estimate, supporting documentation, supplements, or other claim-related materials to my insurance company on my behalf, but subsequently choose not to have Elevated Hail Repair perform the repairs, I agree to pay a $500 Insurance Processing Fee. This fee does not apply if Elevated Hail Repair performs the authorized repairs to my vehicle. If my vehicle is determined to be a total loss, I authorize Elevated Hail Repair to submit charges to my insurance company for claim-related administrative services, including a $650 administrative fee and a $150-per-day vehicle storage fee until the insurance company arranges for removal of the vehicle. I will maintain applicable vehicle insurance while my vehicle is in Elevated Hail Repair’s possession. I release Elevated Hail Repair from liability for loss or damage to the vehicle, subject to applicable law, and acknowledge that my insurance will cover such loss or damage to the extent it is not caused by Elevated Hail Repair. Elevated Hail Repair is not responsible for prior damage to the vehicle, whether exterior or interior, or for damage occurring after the vehicle is returned to me. To secure payment for authorized repairs, I acknowledge an express mechanic’s lien on my vehicle in favor of Elevated Hail Repair. I agree to pay reasonable attorneys’ fees and court costs if legal action is necessary to enforce this agreement. If any provision of this agreement is found unenforceable, it will be enforced to the maximum extent permitted by law or stricken if necessary, and all remaining provisions will remain in full force and effect. Elevated Hail Repair stands behind our workmanship. Repairs performed by Elevated Hail Repair are covered by our Lifetime Limited Warranty for as long as you own the vehicle. This warranty applies to defects resulting from our repair workmanship and does not cover new damage, subsequent accidents, normal wear and tear, manufacturer defects, or damage unrelated to the repairs we performed. I have read and agree to the Work Authorization & Direction of Pay Agreement above. Electronic Signature(Required)By typing my full legal name above and submitting this form, I agree that my electronic signature is legally binding and signifies my acceptance of the Direction of Pay and Work Authorization.Date(Required) Marketing & Promotional Communications Yes, I would like to receive promotional and marketing text messages and emails from Elevated Hail Repair, including special offers, promotions, referral opportunities, and other marketing communications. Consent is not required to purchase services. I may opt out of marketing text messages by replying STOP.
