Deductible Collection and Payment Authorization Form

CSR form for documenting deductible collection method, amount, and customer payment authorization before vehicle release at a collision repair facility.

Submission Details

• CSR / Service Advisor Name
• Shop Location
• Vehicle Release Date
• Repair Order (RO) Number

Customer and Vehicle Information

• Customer Full Name
• Customer Phone Number
• Customer Email Address
  Optional — used to send a payment confirmation receipt.
• Vehicle Year
• Vehicle Make and Model
• Last 6 Digits of VIN
  Used to confirm vehicle identity without capturing the full VIN unnecessarily.

Insurance and Deductible Details

• Insurance Carrier
• Claim Number
• Deductible Amount Owed (USD)
  Enter the exact deductible amount as listed on the approved insurance estimate.
• Deductible Amount Confirmed From
• If Other, Describe Source
• Is Any Portion of the Deductible Being Waived?
  Note: Waiving deductibles without insurer authorization may constitute insurance fraud. Document any waiver carefully.
• Waiver Reason and Authorization
• Actual Amount Collected (USD)
  Enter the amount actually received from the customer. Must match deductible amount unless a documented waiver applies.

Payment Method

• Payment Method Used
• If Other, Describe Payment Method
• Check or Money Order Number
  Record check or money order number for reconciliation purposes.
• Card Last 4 Digits
  Record only the last 4 digits for reference. Never record full card numbers.
• Receipt / Transaction Reference Number
  Record the transaction or receipt number generated by your payment system.
• Payment Plan Terms

Customer Authorization and Consent

• Customer Acknowledgement
  By signing below, the customer confirms: (1) they have reviewed and agree to the deductible amount stated above; (2) the payment method and amount collected are accurate; (3) they authorize release of the vehicle upon completion of this form; and (4) they understand that this record will be retained as part of the repair file.
• Customer Confirms Deductible Amount is Correct
• Customer Confirms Payment Was Made
• Customer Authorizes Vehicle Release
• Customer Signature
  Customer must sign to complete authorization.
• Date Signed

CSR Release Confirmation

• CSR Confirms Payment Received and Verified
• Receipt Provided to Customer
• Vehicle Cleared for Release
• Reason Vehicle is Not Cleared for Release
• Additional CSR Notes
• CSR Signature
  CSR must sign to certify the accuracy of this record.