DIRACTION TO PAY

DIRECTION TO PAYTODISCO SERVICES INC. TAX ID # 043-566· 754

DATE:

TODISCO INVOICE# :

NAME

First Last

ADDRESS:

Street Address City State / Province / Region ZIP / Postal Code

PHONE #:

EMAIL:

VEHICLE INFORMATION

YEAR:

MAKE:

MODEL:

STATE:

PLATE#:

COLOR:

VIN#:

CLAIM INFORMATION:

INSURANCE CO:

CLAIM#:

PHONE #:

EXT:

FAX #:

CLAIM REP:

DATE OF LOSS:.

I understand by signing this form, I understand that I am authorizing the responsible insurance company TO MAKE PAYMENT DIRECTLY TO TODISCO TOWING for any towing, storage and also any other charges that may have incurred from the towing and storage of my vehicle. I understand that if the responsible insurance company does not make payment for these charges, I will be responsible for the total amount due. Once payment has been received I will have twenty four hours to retrieve belongings and make arrangements for disposal or removal of my vehicle.

Signature

Date

PLEASE REFER TO MASS GENERAL LAWS CHAPTER 90, SECTION 34-0

Chapter 90, Section 34-0 was amended in 1989 by adding the third paragraph as follows: An insurer shall not make payments to an individual seeking to collect payment under the provisions of this section, unless the individual has presented a signed direction to pay form described by the commissioner for the loading, unloading and storage of the damaged vehicle to the legally entitled carrier or garage man. All payments to any such certified carrier or garage man shall be made in accordance with these requirements of the completed work claim for as prescribed in this section.

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DIRACTION TO PAY

DIRECTION TO PAYTODISCO SERVICES INC. TAX ID # 043-566· 754

VEHICLE INFORMATION

CLAIM INFORMATION:

PLEASE REFER TO MASS GENERAL LAWS CHAPTER 90, SECTION 34-0

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