Out-of-Pocket Insurance Claim Expenses Disclosure

This form authorizes Budd Baer Collision Center to acknowledge and confirm potential out-of-pocket expenses related to insurance claims processed on behalf of:

Policyholder Information

Claim Details

Acknowledgment of Out-of-Pocket Expenses

I, the undersigned policyholder, understand and acknowledge that despite the existence of insurance coverage, certain expenses related to the above-mentioned claim may not be fully covered by my insurance policy. These potential out-of-pocket expenses may include, but are not limited to:

● Deductibles: The amount I am responsible for paying before my insurance coverage begins.
● Co-payments: A fixed amount I pay for a covered service.
● Co-insurance: A percentage of the cost of a covered service that I am responsible
for after I've paid my deductible.
● Non-covered Services: Services or items explicitly excluded from my insurance
policy or requested by customers unrelated to the insurance claim. (i.e. customer
pay requests)
● Policy Limits: Costs exceeding the maximum amount my insurance policy will pay
for a specific service or event. (i.e. Progressive Policies only pay a max alignment cost of $98.99, the average alignment cost in western PA in 2025 Dealership and Independent Service Centers is $154.55
● Upgrades/Betterments: Costs associated with improvements beyond the original state of the damaged vehicle. (i.e. upgrades to lighting, wheels, AM bumpers, etc.)

I further understand that Budd Baer Collision Center will endeavor to provide estimates of these potential out-of-pocket expenses where feasible, based on the information available at the time. However, I acknowledge that these estimates are not guarantees and actual out-of-pocket expenses may vary depending on the final assessment by the insurance provider, unforeseen circumstances, or additional services required.

Authorization

I hereby authorize Budd Baer Collision Center to proceed with the processing of my insurance claim, understanding that I am responsible for any and all out-of-pocket expenses as outlined above and as determined by my insurance policy and the final claim resolution.

I agree to be responsible for prompt payment of these out-of-pocket expenses upon notification and billing by Budd Baer Collision Center or the relevant service provider.

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Budd Baer Collision Center Authorization To Repair and Order Parts

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AUTHORIZATION TO REPAIR/DIRECTION TO PAY: (PLEASE READ CAREFULLY!)

I hereby authorize Budd Baer Collision Center to order parts, begin repairs on my vehicle, and to make supplemental repairs as necessary to return my vehicle to pre-damage condition. I understand that by signing this form I will be responsible to pay for any parts ordered on my behalf from this point forward. If I don't have my repairs completed at Budd Baer Collision Center within 30 days, and those parts cannot be returned, I will be responsible for the cost or any restocking fees. I understand that all deductibles, prepaid insurance checks and out-of-pocket payments are due in-full at the time I pick-up my vehicle. I hereby grant you and/or your employees permission to operate the vehicle herein described on streets, highways, or elsewhere for the purpose of testing and/or inspection. An Express Mechanic's Lien is hereby acknowledged on above vehicle to secure the amount of repairs thereto. No car can be released Until Payment Is Made In Full. Deductible And Insurance Check Or Proof Of Loss Must Be Received Before Vehicle Will Be Released. Please Be Certain All Payees (Including All Lien Holders) Have Endorsed The Insurance Check Prior To Completion Of Repairs.Budd Baer Collision Center is Not Responsible For Loss Or Damage To Cars Or Articles Left In Cars In Case Of Fire, Theft, Or Any Other Cause Beyond Our Control.

DIRECTION TO PAY:

I authorize Budd Baer Collision Center to bill the third party payer and receive payment directly for my repairs including supplemental charges needed to complete the repairs to my vehicle.

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COMMUNICATION PREFERENCES:

Text Message Updates: I authorize Budd Baer Inc. to utilize text message technology to provide repair information and communication with me. I understand that data rates may apply.

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