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Run: Deductible Collection and Payment Authorization Form

Use this form to record the deductible amount, payment method, and customer authorization before a repaired vehicle is released. It gives the CSR a clear rel...

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Submission Details

CSR / Service Advisor Name (required)

Shop Location (required)

Vehicle Release Date (required)

Repair Order (RO) Number (required)

Customer and Vehicle Information

Customer Full Name (required)

Customer Phone Number (required)

Customer Email Address

Optional — used to send a payment confirmation receipt.

Vehicle Year (required)

Vehicle Make and Model (required)

Last 6 Digits of VIN (required)

Used to confirm vehicle identity without capturing the full VIN unnecessarily.

Insurance and Deductible Details

Insurance Carrier (required)

Claim Number (required)

Deductible Amount Owed (USD) (required)

Enter the exact deductible amount as listed on the approved insurance estimate.

Deductible Amount Confirmed From (required)

If Other, Describe Source

Is Any Portion of the Deductible Being Waived? (required)

Note: Waiving deductibles without insurer authorization may constitute insurance fraud. Document any waiver carefully.

Waiver Reason and Authorization

Actual Amount Collected (USD) (required)

Enter the amount actually received from the customer. Must match deductible amount unless a documented waiver applies.

Payment Method

Payment Method Used (required)

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 (required)

Yes No N/A

Customer Confirms Payment Was Made (required)

Yes No N/A

Customer Authorizes Vehicle Release (required)

Yes No N/A

Customer Signature (required)

Customer must sign to complete authorization.

Date Signed (required)

CSR Release Confirmation

CSR Confirms Payment Received and Verified (required)

Yes No N/A

Receipt Provided to Customer (required)

Vehicle Cleared for Release (required)

Reason Vehicle is Not Cleared for Release

Additional CSR Notes

CSR Signature (required)

CSR must sign to certify the accuracy of this record.

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