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Run: Wiper Blade Free Installation Service Waiver Form

A wiper blade free installation service waiver form that captures customer authorization, vehicle condition, and liability acknowledgment before complimentar...

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Customer Information

Full Name (required)

Phone Number (required)

Email Address

Optional — provided only if you wish to receive a copy of this waiver.

Date of Service (required)

Store Number / Location (required)

Vehicle Information

Vehicle Year (required)

Vehicle Make (required)

Vehicle Model (required)

Vehicle Color

License Plate Number

Optional — used for lot identification only.

Wiper Blade(s) to Be Installed (required)

Pre-Existing Vehicle Condition

Current Windshield Condition (required)

Current Wiper Arm Condition (required)

Additional Notes on Pre-Existing Damage

Optional. Document any damage observed before service begins.

Store associate has visually inspected the vehicle prior to installation (required)

Yes No N/A

Liability Disclaimer & Waiver

Terms and Conditions

Free wiper blade installation is provided as a courtesy service. By signing below, you acknowledge: (1) The store is not liable for damage to wiper arms, windshields, or connectors that results from pre-existing corrosion, wear, or structural weakness. (2) Installation may be declined if the associate determines the wiper arm or windshield is in a condition that poses a risk of damage. (3) This waiver does not affect any statutory rights you may have under applicable consumer protection law.

Exclusion Acknowledgments (required)

I have read and agree to the liability waiver terms stated above (required)

Yes No N/A

Customer Signature (required)

Sign to authorize the free wiper blade installation and confirm acceptance of the waiver terms.

Signature Date (required)

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