Disclaimer | Soapy Sam's Car Wash

While the chances of damage incurring while in any Soapy Sam's location is rare, at times it could happen. We have a damage claim form you can fill out to report damage to your vehicle.

Prior to filling out the form, please read the disclaimer below:

We are Responsible except the following: antennas, wiper blades, bug shields, previous damage, non factory parts or modifications, chrome or molding, damage due to driver error, pontiac mirrors. Reminder: lower power or remove antennas, remove magnetic signs, balls, or flags from antenna, etc.; remove trailer hitch; truck bed MUST be empty and clean.

If you meet the criteria listed above for a damage claim, fill out the following form completely, then sign and submit it. Full and complete responses to all of the requested information will assist in the investigation and processing of your potential claim. Failure to provide all of the requested information may delay or adversely affect the investigation and processing of your potential claim.

PLEASE NOTE: All submittals must be made within 14 days of incident or they will not be heard.

Disclaimer Form

Name

Street Address

Phone Number

City

State

Zip

DL#

Vehicle Make

Model

Year

Color

Mileage

Owner's Name

Date Damage Occurred

Time of Wash

Location of Incident

Employee Present?

Did you speak to an employee?

Describe Vehicle Damage:

Describe, in detail, how the incident occured, including whether the incident was machine related, a collision with a barrier, an incident with the cloth or some other type of incident:

Please read and understand the following Certification before signing this form

I state that my answers on this form are true and correct to the best of my knowledge. I also understand that submitting this form does no indicate that Lighthouse Carwash has accepted responsibility for this matter, and that responsibility will be determined after further investigation and analysis of the facts and circumstances relating to the incident. I further understand and agree that I am providing the requested information voluntarily in order to assist the Lighthouse Carwash Company to investigate the incident, and that, by completing the claims form, I hereby grant my permission to the Lighthouse Carwash Company to the information contained herein and that this form and any additional information my be sent to Lighthouse Carwash Company's insurer or others investigation the incident.

Signature

Date

Damage Claim

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