Authorization and Direction to Pay

Select a Location:*
VEHICLE OWNER’S NAME*
VEHICLE OWNER’S EMAIL*
VEHICLE YEAR*
VEHICLE MAKE*
VEHICLE MODEL*
VIN
CLAIM #
DATE OF LOSS*
Date Format: MM slash DD slash YYYY
Deductible Amount
Insurance Company*
I AGREE THAT PERFORMANCE AUTO BODY LLC WILL NOT BE HELD RESPONSIBLE FOR ANY RENTAL VEHICLE BILLS FOR ANY REASON!!

I AUTHORIZE PERFORMANCE AUTO BODY LLC TO ESTIMATE AND REPAIR MY VEHICLE,UNLESS IT IS AN ECONOMIC TOTAL LOSS

I AUTHORIZE INSURANCE COMPANY TO PAY SUPPLEMENT DIRECT TO PERFORMANCE AUTO BODY LLC WITH THE UNDERSTANDING THAT I WILL BE OBLIGATED FOR PAYMENT IF IT EXCEEDS 30 DAYS FROM BEING SUBMITTED

I ACCEPT TERMS OF DEDUCTIBLE OR BETTERMENTS MUST BE SATISFIED AND DIRECTION OF PAY MUST BE SIGNED BEFORE VEHICLE IS TO BE RELEASED
Vehicle Owner*
Date*
Date Format: MM slash DD slash YYYY
I CERTIFY THAT REPAIRS HAVE BEEN COMPLETED AS INDICATED ON FINAL ESTIMATE AND RE AUTHORIZE DIRECT PAYMENT OF SUPPLEMENT TO PERFORMANCE AUTO BODY LLC WITH THE UNDERSTANDING THAT I WILL BE OBLIGATED FOR PAYMENT IF IT EXCEEDS 30 DAYS FROM BEING SUBMITTED
Vehicle Owner*
Date*
Date Format: MM slash DD slash YYYY