I authorize ____________________ Insurance Company to pay Roadside Collision & Towing directly for repairs done to:

Year______________ Make_____________ Model_________________

Tag #_________________ Serial # ________________________

Claim # _______________________________________

Total ________________________________ _ _ _ _ _ _

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


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