Beverly MAPFRE Insurance CAR/EZ
Name: , Email: , Claim #: , Date of Loss:
I hereby agree to utilize the MAPFRE Insurance CAR/EZ Program for the repair of my Auto Body Clinic
I further agree to allow the CAR/EZ Shop and Commerce Insurance to electronically expedite the repair process of my vehicle in accordance with Massachusetts Regulation 212 CMR.
I hereby authorize AUTO BODY CLINIC to repair the above mentioned vehicle. I agree that I will be responsible to pay the above shop my deductible and any betterment assessed for the repair of my vehicle.
I hereby assign my policy benefits for collision/comprehensive repairs and authorize Commerce Insurance to pay AUTO BODY CLINIC directly for the damages in the amount of arising out of the accident on .
Shop RS # 163, Expiration Date 05-31-2017, Tax ID # 042-694-666, Shop Address 29 River Street, Beverly, MA 01915, Shop Phone 978-922-3334, Shop Fax 978-922-7523
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Document Name: Beverly MAPFRE Insurance CAR/EZ
Agree & Sign