 
 
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 _________________________________________________________________________________________________