I agree on terms and condition

INSURANCE AUTHORIZATION FORM

Insured Name
Street Address
City State ZIP

Email Address

Phone Number

Make of your Car: Select MakeAcuraAudiBentleyBMWBuickCadillacChevroletChryslerDodgeFiatFordFerrariGMCHondaHyundaiInfinitiIsuzuJaguarJeepKiaLand RoverLexusLincolnMaseratiMazdaMercedes BenzMiniMitsubishiNissanPorscheSAABSaturnScionSmartSubaruSuzukiTeslaToyotaVolkswagenVolvoOther

Year of your Car: Select Year202320222021202020192018201820172016201520142013201320122010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986

Model of your Car:

Color: Select ColorRedWhitePearl WhiteBlueBlackBrownYellowGreenGreySilverOther

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 BROTHERS ENTERPRISE INC., and its employees to perform the needed repairs to
my vehicle as well as permission to operate the vehicle here in 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. BLUE STAR BROTHERS ENTERPRISE INC. 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.

DIRECTION OF PAYMENT - BLUE STAR BROTHERS ENTERPRISE INC.
TAX ID#: 82-5090229

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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