I agree on terms and condition

INSURANCE AUTHORIZATION FORM

Insured Name
Street Address
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Insurance Company: Insurance CompanyGEICOPROGRESSIVEALL STATESTATE FARMLIBERTY MUTUALNATIONAL GENERALNATIONALUTICAUTICA NATIONALTRAVELERSUSAACHUBBCOUNTRY WIDETHE GENERALNATIONWIDEESURANCEFARMERSTHE HARTFORDMETLIFESAFECOSENECAEMPIREERIEMAPFRERLISELECTIVEFIREMANS FUNDS INSURANCEFARM INSURANCESENTRYINTERSTATE INDEMNITYINTERBOROKANSAS CITY FIRE AND MARINE INSURANCELIBERTY MUTUAL FIRE21st CENTURYWESCOLM INSURANCENOVAHANOVERAMERICAN TRANSITHARLEYSVILLEHEREFORDINFINITYLANCERCINCINNATIKINGSTONEZURICHFOREMOSTMAIDSTONEAMERIPRISEBERKLEYMID CENTURYAMICABERKSHIREAmGUARDOTHER
Other Insurance Co:
Claim Number:

Agreement; I hereby authorize BLUE STAR COLLISION CENTER LLC., DBA BLUE STAR BROTHERS AUTO REPAIR, and
its employees to perform the needed repairs to my vehicle as well as permission to operate the vehicle herein described on
streets, highways, or elsewhere for the purpose of testing/inspecting. Repairs include parts, labor, materials, and diagnostics.
If on further inspections, additional parts or repairs are needed, you will be contacted for authorization. BLUES STAR
BROTHERS AUTO REPAIR. is not responsible for the availability or delay on parts beyond our control, or for the loss, or
damage to the vehicle, or articles left in the vehicle in the case of a fire, theft, or any cause beyond our control.

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DIRECTION OF PAYMENT - BLUE STAR BROTHERS AUTO REPAIR

TAX ID#: 47-1511973

I do hereby appoint the aforementioned business to accept on my behalf any and all checks, drafts, bills of exchange, and to endorse all such checks, drafts, and bills of exchange for the deposit to the aforementioned business account for credit on my account for repairs on my vehicle which has been released and accepted.

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