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  • Payment Form

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  • I,   *   *   (Customer), request and authorize the following insurer:

  • To make direct payments to the following repair facility:

     

    Repair Facility: Twin Lights Milford Body Shop   Tax ID: 06-0805205

  • of any and all proceeds and proper damage payments related to the above-claim. It is expressly agreed and understood that if any one or more of the property damage payments are sent to me, I am required to immediately turn them over to the repair facility. My failure to remit any property damage checks or otherwise fail to make full payment for repairs will constitute a breach of my repair contract and result in penalties for non-payment, including the accrual of interest to the unpaid balance at a rate of 1.5% per month (18% per annum) and reasonable attorneys' fees and court costs.

    This direction to pay pertains to property damage to the following vehicle:

  • I sign this document of my own free will and accord.

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