Insurance Letter of Direction of Payment Authorization Form

Insurance Letter of Direction of Payment Authorization Form

Please complete the form below to authorize the release of insurance information, and for payment direction.
Year, Make , and Model of RV
Insurance Company
Phone Number to Insurance Company
Please enter a valid phone number.
Email to Insurance Company
example@example.com
Claim Number
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Insurance Policy Number
Insurance Provider
Authorization*

I authorize the release of my insurance information to the designated party.I Request that the Insurance claim payment related to my RV be directed to Texas Xtreme RvT/ RV Tech Connect for the repairts and services provided. Above are the details of the RV and the Claim Information. I Hereby authorize the insurance company to issue all claim payments directly TO: Texas Xtreme RV , 24800 Interstate 45N Suite 120-B, Spring Texas 77386. This directive ensures that the funds are used to cover the repair costs of my Recreational Vehicle. Please acknowledge receipt of this letter and confirm that the necessary arrangements will be made for the payment to Texas Xtreme RV /RV TECH CONNECT, to receive Payment either EFT or CHeck Overnight. If you have any question or require further information, please do not hesitate to contact me at the information above. Thank you for your prompt attention to this matter
Signature*

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I Request that the Insurance claim payment related to my RV be directed to Texas Xtreme RvT/ RV Tech Connect for the repairts and services provided. Above are the details of the RV and the Claim Information. I Hereby authorize the insurance company to issue all claim payments directly TO: Texas Xtreme RV , 24800 Interstate 45N Suite 120-B, Spring Texas 77386. This directive ensures that the funds are used to cover the repair costs of my Recreational Vehicle. Please acknowledge receipt of this letter and confirm that the necessary arrangements will be made for the payment to Texas Xtreme RV /RV TECH CONNECT, to receive Payment either EFT or CHeck Overnight. If you have any question or require further information, please do not hesitate to contact me at the information above. Thank you for your prompt attention to this matter .
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