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Document Sample

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 _________________________________________________________________________________________________

Document Information

Fact Name Details
Purpose The Authorization and Direction to Pay form allows a claimant to direct an insurance company to pay a repair facility directly for services rendered.
Claim Information The form requires specific claim details, including the claimant's name, license plate, and insurance company information.
Authorization Requirement The claimant must authorize the insurance company to pay the repair facility directly, ensuring funds go where they are needed.
Notification Clause If the insurance company mistakenly sends the check to the claimant, they must notify the repair facility within 24 hours.
Signature Requirement The form must be signed by the claimant, which confirms their consent and understanding of the payment direction.
Body Shop Information Details of the body shop, including name, tax ID, address, and contact information, must be provided for processing the payment.
State-Specific Laws In many states, this form is governed by insurance regulations that dictate how claims and payments must be handled.
Importance of Accuracy All information on the form must be accurate to prevent delays in payment or processing issues.
Form Accessibility This form is often available through insurance companies, body shops, or online legal resources to ensure easy access for claimants.

Authorization And Direction Pay - Usage Guidelines

After completing the Authorization And Direction Pay form, it is essential to ensure that all required information is accurately filled out. This form facilitates the payment process between the insurance company and the repair facility. Follow these steps to complete the form correctly.

  1. Begin by entering your Name in the designated space.
  2. Fill in your License Plate number.
  3. Provide your Address, ensuring all details are complete.
  4. Input your Home Phone number.
  5. Include your Business/Cellphone number.
  6. Indicate the Year of your vehicle.
  7. Specify the Make of your vehicle.
  8. Fill in the Model of your vehicle.
  9. Enter the name of your Insurance Company.
  10. Provide your Claim #.
  11. In the DIRECTION TO PAY section, write the name of the insurance company that will be making the payment.
  12. Next, enter the name of the party who will receive the payment directly.
  13. Fill in the claim number for the payment.
  14. Indicate the amount to be paid.
  15. Read the statement regarding the handling of checks and sign your Customer Printed Name.
  16. Sign the form in the Customer Signature section.
  17. Record the Date of signing.
  18. Provide the Body Shop name and address.
  19. Include the Body Shop Tax ID.
  20. Fill in the Body Shop Phone number.
  21. Finally, enter the Body Shop Contact name.

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Dos and Don'ts

When filling out the Authorization And Direction Pay form, it is important to follow specific guidelines to ensure a smooth process. Here’s a list of things to do and avoid:

  • Do provide complete and accurate information in all fields, including your name, address, and claim details.
  • Do clearly indicate the insurance company and the amount to be paid.
  • Do sign and date the form to validate your authorization.
  • Do notify the repair facility immediately if you receive the settlement check by mistake.
  • Don't leave any fields blank; incomplete forms may delay processing.
  • Don't forget to double-check the claim number and payment amount for accuracy.
  • Don't submit the form without confirming that all required signatures are present.

By adhering to these guidelines, you can help ensure that your claim is processed efficiently and without unnecessary delays.

Common mistakes

  1. Incomplete Information: Failing to fill out all required fields can lead to delays. Ensure that the name, address, and claim number are fully completed.

  2. Incorrect Insurance Company Details: Providing the wrong name of the insurance company can result in payment issues. Double-check the spelling and accuracy of the insurance company’s name.

  3. Missing Signature: Omitting the customer signature can invalidate the form. Always sign and date the form to confirm authorization.

  4. Failure to Notify: Not agreeing to notify the repair facility if a check is received can complicate the payment process. It is crucial to understand and accept this responsibility.

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