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,  & 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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