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DIRECTION TO PAY FORM OWNER/CLAIM INFORMATION Name __________________________________________________________________ License Plate ______________________________ Address ____________________________________________________________________________________________________________ Home Phone _________________________________________ Business/Cellphone __________________________________________ Year _____________________
Make _____________________ Model ______________________________________________________
Insurance Company ___________________________________ Claim # _____________________________________________________
DIRECTION TO PAY I authorize _____________________________________________ Insurance Company to pay ____________________________________ directly on claim number ________________________________ in the amount of $___________________. In the event the insurance or adjustment company inadvertently mails the settlement/supplement check to me in error, I hereby agree to notify the repair facility immediately and deliver the check to that facility within 24 hours of my receipt of said check.
Customer Printed Name
Customer Signature
Date
Body Shop _________________________________________________________________________________________________________ Body Shop Tax ID ___________________________________________________________________________________________________ Body Shop Address _________________________________________________________________________________________________ Body Shop Phone ___________________________________________________________________________________________________ Body Shop Contact _________________________________________________________________________________________________
