ASSIGNMENT OF BENEFITS
I hereby assign any and all insurance rights, benefits and proceeds under any applicable insurance policies to XCLUSIVE LEVEL AUTO GLASS, LLC. I make this assignment in consideration of XCLUSIVE LEVEL AUTO GLASS, LLC’s agreement to perform services and supply materials and otherwise perform its obligations under this contract, including not requiring full payment at the time of service. If payment is made directly to owner/agent by an insurer, it shall be endorsed over to XCLUSIVE LEVEL AUTO GLASS, LLC. within three (3) days. I agree that any portion of work not covered by insurance must be paid by the undersigned on or before its completion. I hereby direct my insurance carrier to release any and all information requested by XCLUSIVE LEVEL AUTO GLASS, LLC. and to accept notice of the claim from XCLUSIVE LEVEL AUTO GLASS, LLC.
PLEASE READ CAREFULLY, CHECK ONE OF THE STATEMENTS BELOW, AND SIGN:
I UNDERSTAND THAT, UNDER STATE LAW, I AM ENTITLED TO A WRITTEN ESTIMATE IF MY FINAL BILL WILL EXCEED $100.
___ I REQUEST A WRITTEN ESTIMATE.
___ I DO NOT REQUEST A WRITTEN ESTIMATE AS LONG AS THE REPAIR COSTS DO NOT EXCEED $______. THE SHOP MAY NOT EXCEED THIS AMOUNT WITHOUT MY WRITTEN OR ORAL APPROVAL.
___ I DO NOT REQUEST A WRITTEN ESTIMATE.
_________________________ ___________
SIGNED DATE
Florida Statutes
Title XXXIII
REGULATION OF TRADE, COMMERCE, INVESTMENTS, AND SOLICITATIONS
Chapter 559
REGULATION OF TRADE, COMMERCE, AND INVESTMENTS, GENERALLY
559.905 Written motor vehicle repair estimate and disclosure statement required.—
(1) When any customer requests a motor vehicle repair shop to perform repair work on a motor vehicle, the cost of which repair work will exceed $100 to the customer, the shop shall prepare a written repair estimate, which is a form setting forth the estimated cost of repair work, including diagnostic work, before effecting any diagnostic work or repair. The written repair estimate shall also include the following items:
(a) The name, address, and telephone number of the motor vehicle repair shop.
(b) The name, address, and telephone number of the customer.
(c) The date and time of the written repair estimate.
(d) The year, make, model, odometer reading, and license tag number of the motor vehicle.
(e) The proposed work completion date.
(f) A general description of the customer’s problem or request for repair work or service relating to the motor vehicle.
(g) A statement as to whether the customer is being charged according to a flat rate or an hourly rate, or both.
(h) The estimated cost of repair which shall include any charge for shop supplies or for hazardous or other waste removal and, if a charge is included, the estimate shall include the following statement:
“This charge represents costs and profits to the motor vehicle repair facility for miscellaneous shop supplies or waste disposal.”
If a charge is mandated by state or federal law, the estimate shall contain a statement identifying the law and the specific amount charged under the law.
(i) The charge for making a repair price estimate or, if the charge cannot be predetermined, the basis on which the charge will be calculated.
(j) The customer’s intended method of payment.
(k) The name and telephone number of another person who may authorize repair work, if the customer desires to designate such person.
(l) A statement indicating what, if anything, is guaranteed in connection with the repair work and the time and mileage period for which the guarantee is effective.
(m) A statement allowing the customer to indicate whether replaced parts should be saved for inspection or return.
(n) A statement indicating the daily charge for storing the customer’s motor vehicle after the customer has been notified that the repair work has been completed. However, no storage charges shall accrue or be due and payable for a period of 3 working days from the date of such notification.
(2) If the cost of repair work will exceed $100, the shop shall present to the customer a written notice conspicuously disclosing, in a separate, blocked section, only the following statement, in capital letters of at least 12-point type:
PLEASE READ CAREFULLY, CHECK ONE OF THE STATEMENTS BELOW, AND SIGN:
I UNDERSTAND THAT, UNDER STATE LAW, I AM ENTITLED TO A WRITTEN ESTIMATE IF MY FINAL BILL WILL EXCEED $100.
I REQUEST A WRITTEN ESTIMATE.
I DO NOT REQUEST A WRITTEN ESTIMATE AS LONG AS THE REPAIR COSTS DO NOT EXCEED $ . THE SHOP MAY NOT EXCEED THIS AMOUNT WITHOUT MY WRITTEN OR ORAL APPROVAL.
I DO NOT REQUEST A WRITTEN ESTIMATE.
SIGNED DATE
(3) The information required by paragraphs (1)(h) and (i) need not be provided if the customer waives in writing her or his right to receive a written estimate.
(4) Except as provided in subsection (5), a copy of the written repair estimate required by subsection (1) and the disclosure statement required by subsection (2) shall be given to the customer before repair work is begun. The disclosure statement may be provided on the same form as the written repair estimate.
(5) If the customer leaves her or his motor vehicle at a motor vehicle repair shop during hours when the shop is not open or if the customer permits the shop or another person to deliver the motor vehicle to the shop, there shall be an implied partial waiver of the written estimate; however, upon completion of diagnostic work necessary to estimate the cost of repair, the shop shall notify the customer as required in s. 559.909(1).
(6) Nothing in this section shall be construed to require a motor vehicle repair shop to give a written estimated price if the motor vehicle repair shop does not agree to perform the requested repair.