Hanover Insurance Form CITIZENS/HANOVER INSURANCE COMPANIES EXPRESS CLAIMS AUTHORIZATION FOR PAYMENTDirections: 1) This form should be signed by the vehicle owner(s) and a witness after the repairs have been completed. 2) A copy of this thoroughly completed form should be provided to the vehicle owner(s). 3) Total cost of repairs must match the amount submitted electronically through Autoverse or Pathways.Underwriting Company Name from Appraisal Assignment (Required for Payment)CLAIM #:(Required) POLICY #: Vehicle Owner's Name:(Required) First Last Insured's Name: First Last This is to certify that the damages estimated or appraised have been repaired to my satisfaction and the Citizens/Hanover Insurance Company is hereby authorized to issue payment only in the name of:Name of Repair Shop Tax ID Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Repair Shop Phone NumberRepair Shop Fax Numberfor the repairs to my vehicle in the net amount shown below. I understand that I am responsible for any applicable deductible, adjustment for depreciation and/or betterment amount shown below. I have received a copy of the appraisal of damages and the final bill.Vehicle Owner's Signature:Date MM slash DD slash YYYY Witness’ Signature:Date MM slash DD slash YYYY Repair Facility: I certify the vehicle repairs and final invoice reflects compliance with the Express Claims program guidelines.Repair Facility Signature:Date MM slash DD slash YYYY Total Amount for the cost of repairs:a) Insured is responsible for their collision or comprehensive deductible in the amount of:b) Vehicle owner is responsible for the depreciation or betterment adjustment in the amount of:c) Total amount (from a & b) payable by the vehicle owner to the Express Claim Shop:Net amount due above named Express Claim Shop from Citizens/Hanover Insurance Companies:To Receive Payment:This form must be thoroughly completed and emailed to ECSHOP@hanover.com or faxed to 888-766-1814 or 888-766-1813 within 48 hours of completion of repairs. If the Tax ID number is not provided, payment will be issued one party to the insured. Please send only one form per fax or email
