Verification & Liability

Verification & Liability Agreement. Complete and sign below — your submission goes straight to the office.

The Ding Xpert LLC

Paintless Dent & Hail Repair · (469) 400-0322

545 Reed Lane, Suite 5, Gunter, TX 75058

Customer Verification & Liability Agreement

An addendum to the Repair Order / Direction of Payment Form

Customer & Vehicle Information

Customer Name *

Date

Vehicle Make

Vehicle Model

Vehicle VIN

Customer Acknowledgment

This agreement verifies that all information you provided on the Repair Order / Direction of Payment Form is accurate and complete, and it outlines your responsibility for any falsified or omitted details related to your personal information or insurance claim. By checking the boxes below, you affirm the following:

All personal information I provided on the Repair Order Form is accurate and truthful.

I have disclosed any prior claims filed with my insurance provider for the damage being assessed and repaired by The Ding Xpert.

I have provided The Ding Xpert with all relevant initial estimates or claims related to the damage in question.

Liability for Falsified or Omitted Information

I understand and agree that I may be liable for a fee of up to $2,500 if any of the following occur:

I provide false or misleading personal information on the Repair Order Form.
I omit or fail to disclose any prior claims, estimates, or checks received or deposited related to the damage being assessed and repaired.
I falsify or misrepresent any information from my vehicle insurance provider.

This fee covers administrative costs, delays, and potential financial losses incurred by The Ding Xpert due to misrepresentation.

Verification of Claim Disclosure

Please select the option that applies to you:

I have never filed a prior claim with my insurance provider for the damage being assessed. I have previously filed a claim with my insurance provider for the damage being assessed, and I have disclosed all relevant details to The Ding Xpert.

Legal & Financial Responsibility

The Ding Xpert has the right to verify all information provided, including contacting my insurance provider.
Any false or misleading information may result in additional legal action to recover damages.
This agreement is binding and enforceable under the laws of the State of Texas.

Special Request / Add-On

Notes (optional)

Agreement

I have read and understood this agreement and agree to its terms.

Date

Customer Signature

Sign below using your finger or mouse

Submission goes directly to The Ding Xpert LLC office