Back to Mechanic Affidavit Form – Select Your State

If your customer has a LifeSafer ignition interlock device installed in their vehicle, please fill out the form below, and a mechanic’s code will be provided to you so you can safely complete the needed repairs. Please be sure to complete the entire form.

This form is to be completed only by the certified mechanic performing the work. Once submitted, LifeSafer will review all information and if there are questions, you may be asked to provide additional information.

Instructions

Complete this form in 5 steps and upload the form and documents. You can also fax or email the completed form to LifeSafer®.

You can also return completed forms to:
FAX: (844) 663-9931
Email: client.services@lmgholdings.com

MECHANICAL BYPASS authorization codes are required by a monitoring authority when the interlock-equipped vehicle is serviced.
The client must use a licensed service center.

1. To authorize bypass, complete this form order.

2. Attach a copy of the work order on company letterhead, invoices, and/or receipts associated with this vehicle service/repair.

3. Submit this form via fax, email, or uploading it to our website. Once received, LifeSafer will review and contact the mechanic directly with further bypass instructions.

**Please be advised this may take up to 2 business days.

TO BE COMPLETED BY THE MECHANIC PERFORMING THE WORK

Mechanic Service Code Request (E-Sign)

Step 1 of 4

LifeSafer Client Information
All LifeSafer client information must be for the individual to who the ignition interlock is assigned too.
Restricted Driver Information (Enter name as it appears on the client's Drivers License)*
First Last
Driver's License #:*
Phone:*
Email:*
Representative Name (if known):

Mechanic | Automotive Repair Facility Information
Review for accuracy
Name of Service Facility:*
City:*
State*
Zip:*
Date Service Started:*
MM slash DD slash YYYY
Time:*

: Hour

Minutes

AM/PM
Est Date of Completion:*
MM slash DD slash YYYY
Time:*

: Hour

Minutes

AM/PM
Tax ID Number: (Only required for Virginia Mechanics)
Mechanic/Automotive Performing Tech Work Name:*
First Last

TO BE COMPLETED BY THE MECHANIC PERFORMING THE WORK
Is your service center licensed?*
Provide your business license number:*
Verification: Is your service center ASE-Certified?*
LifeSafer only provides mechanic codes to certified mechanics at accredited businesses. California and Michigan require mechanics have state certifications.
Are you ASE-Certified?*
Mechanic Agreement
All fields MUST be checked in order to be assisted.
Consent*
By checking this box, I understand and agree to all statements below*
I, or my coworkers will be in sole possession of the above mentioned vehicle during the date(s) of service listed herein. The LifeSafer client that is subject to the interlock restriction will not drive the vehicle during the date(s) that I am performing services on the vehicle.

I will be responsible for performing service on the vehicle listed above during the date(s) of service listed herein. I understand that unless the LifeSafer client will be in the vehicle to operate the interlock device the entire time work is being performed, (which I will inform LifeSafer if this is the case) that I will need a mechanic’s code from LifeSafer along with instructions prior to working on the vehicle. (The code and will be provided once the completed form has been received and processed. The instructions will be available online upon completion of this form.)

I will not provide the mechanic code(s) or copies of the instructions to the LifeSafer client or any third party.
Please submit the signed and completed mechanic affidavit, the mechanic’s official work order and receipts.
Mechanic’s Official Work Order*
Accepted file types: pdf, Max. file size: 100 MB.
Receipts
Accepted file types: pdf, png, jpg, Max. file size: 100 MB.
Mechanic Authorization: Must be signed by the certified mechanic performing the work.
I certify under penalty of perjury, that the foregoing information is true and correct.
Date:*
MM slash DD slash YYYY
Address*
Street Address City State ZIP Code
Signature:*

Instructions

Mechanic Service Code Request (E-Sign)

Step 1 of 4

LifeSafer Client Information

Vehicle Information

Mechanic | Automotive Repair Facility Information

TO BE COMPLETED BY THE MECHANIC PERFORMING THE WORK

Mechanic Agreement

Please submit the signed and completed mechanic affidavit, the mechanic’s official work order and receipts.

Mechanic Authorization: Must be signed by the certified mechanic performing the work.