Direction of Pay

Tax ID# 222-497-047/000



NJ License# 01563A

Insurance Company:
Customer Name:
Claim #:
Policy #:

You are hereby authorized to forward payment for repairs and/or supplements Directly to D & M Auto Body.

Date :

Any Checks received by a claimant or insured, must be turned over to D&M Auto Body immediately. Any attempt to withhold payment after singing this document could result in the claimant or insured being charged with insurance fraud and fined. To secure payment for the above repair balance, I acknowledge that D & M Auto Body has a mechanics lien on my vehicle until all such repair cost have been paid. I further agree to pay reasonable attorney's fees, court costs and interest in the event that legal action is necessary.

Please enter your information


Name:
Email:
Please enter the characters in the image
captcha