www.mapfreinsurance.com MAPFRE Insurance CAR EZ ® Program Print Name Date Signature Direction To Pay I hereby assign my policy benefits for collision/comprehensive repairs and authorize MAPFRE Insurance to pay ________________________________________________________ directly for the damages in the amount of $ ___________________________ arising out of the accident on ____________________________ . (Shop Name) (Date)
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www.mapfreinsurance.com
MAPFRE Insurance CAR EZ® Program
Print Name
Date
Signature
Direction To Pay
I hereby assign my policy benefits for collision/comprehensive repairs and authorize MAPFRE Insurance to pay
________________________________________________________ directly for the damages in the amount of $ ___________________________
arising out of the accident on ____________________________ .(Shop Name)
(Date)
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