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Roadside Consent
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customer name
*
First
Last
email
*
Vehicle Location Model)
phone
Vehicle (Year, Make, Model)
VIN
License Plate
Service Location
Service Type
Jump start
Tire change
Fuel delivery
Lockout
Other
Agreement
I Agree to the terms and conditions
I consent to roadside or emergency service at the location above and agree to the $50 call-out fee plus $1.05 per mile. I release HL Service and Mechanics LLC from liability for incidents caused by the roadside environment, including traffic, weather and uneven ground.
Digital Signature
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