Insurance Repair Authorization Form

Insurance Form

UNIVERSE AUTO BODY CENTER INC.
1825 GIVAN AVE – BRONX, NEW YORK 10469.
PHONE (718) 379-2100 FAX (347) 202-9091.
TAX ID # 13-3501342

Owner

First

Last

Information Insurance Deductible

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Vehicle Information

Make

Model

Year

License Plate Number

Please include state

Insurance Information

Insurance Company

Claim Number

Insurance Deductible

Signature

I AUTHORIZE UNIVERE AUTO BODY CENTER INC. TO BE MY DESIGNATED REPRESENTATIVE FOR THE PURPOSE OF NEGOTIATING THIS INSURANCE CLAIM. IF THE VEHICLE IS COMPLETED AND IT HAS NOT BEEN PICKED UP WITHIN 3 DAYS OF COMPLETION DATE, A STORAGE FEE WILL BE ADDED TO BILL.

Repair Authorization

Clear Signature

I AUTHORIZE UNIVERSE AUTO BODY CENTER INC. TO REPAIR THIS VEHICLE

Payment Authorization

Clear Signature

I AUTHORIZE PAYMENT TO BE MADE DIRECTLY TO UNIVERSE AUTO BODY CENTER INC.

Insurance Form

Vehicle Information

Insurance Information

Signature

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