Assignment Of Insurance Proceeds printable pdf download

Assignment Of Insurance Proceeds

Assignment of Insurance Proceeds

o w n e r n a m e

, am the owner of the

y e a r / m a k e / m o d e l

with vehicle identification number

v i n

(the “Vehicle”) insured by

(“Insurer”) under

i n s u r a n c e c o m p a n y

(the “Policy”).

Policy Number

p o l i c y n u m b e r

I hereby authorize any and all insurance payments for repairs of my Vehicle under Claim

(the “Claim”) to be made to [YOUR SHOP NAME

Number

c l a i m n u m b e r

HERE] (“Repair Shop”). I authorize Repair Shop to accept on my behalf and endorse any and

all checks, drafts or bills of exchange for deposit as credit on my account for repair of my

Vehicle.

I hereby assign all claims and causes of action for repair of my Vehicle that I may have against

Insurer under the Policy and/or the Claim. I agree to cooperate with Repair Shop in any action

or other effort it makes to collect from Insurer.

I acknowledge that I am responsible for any deductible, adjustment for depreciation or other

adjustments under the Policy. I agree to pay such deductible or adjustments.

I acknowledge and agree that if Insurer fails to pay for repairs to my Vehicle, I will be liable for

the full cost of repairs to my Vehicle. I further acknowledge and agree that if the Policy

prohibits this assignment of proceeds to Repair Shop, I will be responsible for payment of the

full cost for the repair of my Vehicle.

I acknowledge that the total amount due for repairs of my Vehicle must be paid to Repair Shop

before the Vehicle will be released by Repair Shop.

Signature:

Printed Name:

Date:

Assignment Of Insurance Proceeds