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Preview - Authorization And Direction Pay Form
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 _________________________________________________________________________________________________
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Similar forms
The Authorization and Direction Pay form shares similarities with several other documents commonly used in insurance and claims processes. Here are six such documents:
- Power of Attorney: This document grants someone the authority to act on your behalf in legal or financial matters, similar to how the Authorization and Direction Pay form allows an insurance company to pay directly to a repair facility.
- Assignment of Benefits: This form allows a third party, like a service provider, to receive payment directly from the insurance company. It functions similarly by directing payment to a specific entity.
- Release of Liability: This document releases one party from liability, often used in settlement agreements. It shares the purpose of directing funds to resolve claims.
- Claim Authorization Form: This form authorizes an insurance company to process a claim on behalf of the policyholder. It is similar in that it establishes permission for payment to be made.
- Trailer Bill of Sale: Essential for documenting the sale of a trailer in Missouri, this form serves as a crucial proof of purchase and verifies ownership transfer. For more details, refer to the Motor Vehicle Bill of Sale.
- Direct Deposit Authorization Form: This document allows funds to be deposited directly into a bank account. Like the Direction to Pay form, it facilitates direct payment but for bank transactions.
- Settlement Agreement: This document outlines the terms of a settlement, including payment instructions. It resembles the Direction to Pay form by detailing how and to whom payments should be made.