Beverly MAPFRE Insurance CAR/EZ


 

 

Name: Email:    , Claim #:   , Date of Loss:   

Release Authorization and Shop Repair Authorization

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.

Direction to Pay

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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Signature Certificate
Document name: Beverly MAPFRE Insurance CAR/EZ
Unique Document ID: 74c5d916defd096d74204d535d78fd85051a1d60
Timestamp Audit
August 22, 2017 4:01 pm EDTBeverly MAPFRE Insurance CAR/EZ Uploaded by Stephen Arena - lisa@autobodyclinic.com IP 73.218.116.7