Mapfre Form CLAIM NUMBER(Required) DATE OF LOSS(Required) MM slash DD slash YYYY Name(Required) First Last RELEASE AUTHORIZATION AND SHOP REPAIR AUTHORIZATIONI hereby agree to utilize the MAPFRE Insurance CAR EZ® Program for the repair of my Vehicle Information(Required) Shop Name(Required) I further agree to allow the CAR EZ® Shop and MAPFRE Insurance to electronically expedite the repair process of my vehicle. (MA – in accordance with Massachusetts Regulation 212 CMR.) I hereby authorize @{:10} to repair the above mentioned vehicle. I agree that I will be responsible to pay the above shop my deductible and any betterment assessed to me for the repair of my vehicle.DIRECTION TO PAYDamages Amount(Required)I hereby assign my policy benefits for collision/comprehensive repairs and authorize MAPFRE Insurance to pay @{:10} directly for the damages in the amount of @{:23} arising out of the accident on @{:4}.Print Name(Required) Signature(Required)Date(Required) MM slash DD slash YYYY Shop Reg #: Expiration Date: MM slash DD slash YYYY Tax ID #:
