Direction To Pay Repair Order # (if known) Vehicle Owner Name First Last Vehicle Description(Required) Vehicle Identification Number(Required) Insurance Company(Required) Claim Number(Required) Consent(Required) I agree to this DTPI authorized the insurance company to send payment for repairs directly to Smitty’s Maintenance Repair & Collision, Inc. In the event the insurance or other party inadvertently mails the settlement/supplement check to me, I hereby agree to notify the said shop immediately, and I agree to deliver such check to the repair facility with 24 hours of my receipt of such check. Be aware in the event an insurance company is not responding to our submission for supplement and payment we will request the customer to follow up with the insurance company. This may cause the customer to be responsible for costs incurred from the vehicle repair and then customer can be reimbursed from insurance.Customer Printed Name(Required) First Last Date(Required) MM slash DD slash YYYY Signature(Required) Reset signature Signature locked. Reset to sign again Δ
