Ability Homecare

Automobile Liability Release – Client

At my own discretion, I will be using my own automobile as part of the care rendered by my caregivers.

I agree that I have full responsibility for my automobile insurance. I agree not to hold Ability Homecare responsible for any accident in which there is damage to my automobile or injury to its occupants.

Your Name(Required)

First Last

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Year / Make / Model(Required)

Color of Vehicle(Required)

License Plate(Required)

Insurance Company(Required)

Telephone(Required)

Policy Number(Required)

Expiration(Required)

You will be prompted immediately to sign release form upon submission.

Today's Date(Required)

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